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Claims Examiner

1 month ago

San Francisco, United States San Francisco Health Plan Full time

Reporting to the Manager, Claims, the Claims Examiner is responsible for claims processing, adjudication, and research. You will stay current on claim processing procedures, produce a quality work product, and assist Claims Management with special projects. You will have claims processing experience with the ability to maintain high qualitative and quantitative standards established for this position.

Salary: $28.00 - $32.00/hour

WHAT YOU WILL DO:

  • The accurate processing, adjudication and claims research to include:

    • Keep the department‘s claim inventory current and clear edit queues by process claims according to verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing.
    • Use the QNXT claims processing module to process claims.
    • Meet production and quality standards when processing claims and performing tasks.
    • Handle call tracking tickets promptly regarding claims status, billing and payment issues, disputes, etc.
    • Stay informed about the changes in Medi-Cal regulations, program policies and current processing procedures.
    • Foster an environment that solicits and enlists diverse and inclusive perspectives and approaches to better serve our staff, our members and our providers.

WHAT YOU WILL BRING:

  • One year prior work experience in medical claims processing preferably with focus on Medi-Cal claims.
  • Hands-on working knowledge and background using claims processing systems.
  • Knowledge of CPT/HCPCS, ICD-9 coding, medical terminology and managed care principles.
  • A high school diploma or equivalent work experience.
  • Demonstrated working knowledge of editing claims systems such as QNXT.
  • Experience in Excel, Word, Outlook, and other MS products

WHAT WE OFFER:

  • Health Benefits
    • Medical: You‘ll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
    • Dental: You‘ll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
    • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
  • Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
  • Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays.
  • Professional development: Opportunities for tuition reimbursement, professional license/membership.

ABOUT SFHP:

Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.

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