Claims Examiner II

San Francisco Health Plan • San Francisco, CA

52d • $34 - $39 • Hybrid

About The Position

Reporting to Supervisor, Claims, the Claims Examiner II, is accountable for claims processing, adjudication, claims research and claims inquiries escalated from Customer Service. Must meet qualitative and quantitative standards established for this position. You will maintain claims inventory to achieve departmental metrics and process all types of claims according to regulatory requirements. Also, you must follow current claims processing procedures, produce a quality and timely work product, and assist Claims management with internal audits and special projects. Please note that while SFHP supports a hybrid work environment, the Claims Examiner II is not required to meet the minimum in-office requirement of 4x/month, but is required to attend company meetings and other in-person events at Supervisor's discretion. Salary: $33.65 - $38.94 per hour

Requirements

• 2 years prior work experience in claims operations environment and health care insurance business, preferably with focus on Medi-Cal claims.
• Hands-on working knowledge and background using claims processing systems.
• Demonstrated working knowledge of any editing claims system, QNXT is preferred.
• Knowledge of CPT/HCPCS, ICD-10 coding, medical terminology, and managed care principles.
• A high school diploma or equivalent

Nice To Haves

• Knowledge of Claims Editing Software preferred.

Responsibilities

• Keep claims inventory current to achieve departmental metrics.
• Clear edit queues by processing claims according to verification of eligibility, and interpretation of program benefits, and provider contracts including manual pricing.
• Conform to established standards of performance for quality and timeliness.
• Correctly match authorizations to claims.
• Coordinate benefits/other health coverage.
• Use the QNXT claims processing module in an effective and efficient manner to process claims.
• Meet production and quality standards when processing claims and performing tasks.
• Interpret medical group and provider contracts to determine claims payment methodologies.
• Review and adjudicate claims (paper and EDI) and resolve claim edits, using claims desktop procedures and reference materials.
• Review claims for correct provider coding information and the appropriateness of reported services and billing practices.
• Review claims for necessity, limitations and exclusions based on claims policies and procedures.
• Reprocess and adjust claims when needed.
• Process retro-terminations.
• Process refunds and other overpayment recovery recoupments when needed.
• Handle smaller scale projects in claims from start to finish.
• Work with Claims Management to identify system and/or training-related opportunities that contribute to the enhancement of operating results.
• Handle provider call tracking tickets promptly and courteously regarding claims status, billing, and payment issues.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Administration of Human Resource Programs
• Education Level: High school or GED
• Number of Employees: 251-500 employees