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At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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Hill Physicians has much to offer prospective employees. We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

To research, facilitate resolution, and follow-through with outcome of Appeals & Grievances (A&G) within expected timeframes.

Job Responsibilities

• Research A&G cases utilizing main database (IDX).
• Verify governing sources (e.g., guidelines, contract language, benefits, etc.).
• Extract and outline pertinent case details.
• Present appeal cases to Medical Directors to obtain final determination.
• Compose and type correspondence to health plans.
• Update specific member records in main database (IDX).
• Maintain specific and accurate log of the A&G process for each case.
• Serve as back-up to Case Coordinator.
• Perform other duties as required.

Required Experience

• Two years’ minimum managed healthcare experience. Excellent verbal and written communication.
• Strong assessment and analytical skills.
• Resourceful in problem solving.
• Ability to prioritize.
• Responsible and accountable.
• Highly organized.
• Thorough and attentive to detail.
• Excellent follow-through.
• Medical terminology preferable.
• Computer literate (familiarity w/ MS Word and IDX preferable).
• Ability to type 45-55 wpm.
• Dependable and discrete.

Required Education

• High School graduate. Some college helpful.

Additional Information

Hill Physicians is an Equal Opportunity Employer

POSITION DESCRIPTION

TITLE: Appeals and Grievances Case Analyst

SUPERVISOR: Manager, Quality Management

DEPARTMENT: Compliance

GRADE: 3

PURPOSE: To research, facilitate resolution, and follow-through with outcome of Appeals & Grievances (A&G) within expected timeframes and in accordance with PriMed Policies and Procedures.

Key Responsibilities and Tasks:

Essential Responsibility
100%

• Research A&G cases utilizing main database.
• Verify governing sources (e.g., guidelines, contract language, benefits, etc.).
• Extract and outline pertinent case details.
• Assist in the composing of Case Summaries for presentation to Medical Directors to obtain final determination.
• Compose and type correspondence to health plans, provider offices and relevant internal business areas.
• Update specific member records in relevant main databases.
• Assist in the maintenance of accurate logs of the A&G process for each case.
• Perform other duties as required.

.
Skills and Experience Required:

• Two years’ minimum managed healthcare experience. Excellent verbal and written communication.
• Strong assessment and analytical skills.
• Resourceful in problem solving.
• Ability to prioritize.
• Responsible and accountable.
• Highly organized.
• Thorough and attentive to detail.

• Excellent follow-through.
• Medical terminology experience.
• Computer literate (familiarity w/ Microsoft applications (MS Teams, Outlook, Word, excel, and PowerPoint) and databases preferable).
• EMR and database experience preferred.
• Ability to type 45-55 wpm.
• Understanding of HIPAA regulations.
• Dependable and discrete.
• Ability to work both independently and as part of a team.

Required Education:

• High School graduate. Some college helpful

Job Title Default Appeals and Grievances Analyst
Restrict to Country
Management Level Individual Contributor
Job Family 3503 Compliance
Job Category
Job Classifications 5 - Administrative Support Workers (EEO-1 Job Categories-United States of America)
Bonus Level 2 - (Bonus Level)
Work Shift Required No
Public Job Yes
Referral Payment Plan

Characteristics

Difficulty to Fill
Critical Job No

Compensation Grade PriMed Exempt Grade 3

Compensation Grade Profile

Impacted Eligibility Rules

Job Type: Full-time

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