The Claims Examiner is responsible for claims processing, adjudication, and research.
In addition, this position keeps current on claim processing procedures, produces a quality and timely work product, and assists Claims Management with special projects as needed.
The ideal candidate will have claims processing experience with the ability to maintain high qualitative and quantitative standards established for this position.
WHAT YOU WILL DO
The accurate and timely 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.Utilize 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.
Reprocess claims when necessary.
Handle call tracking tickets promptly regarding claims status, billing and payment issues, disputes, etc.
Stay abreast of the changes in Medi-Cal regulations, program policies and current processing procedures.
WHAT YOU WILL BRING
Minimum of 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; college degree preferred.
Detail oriented with problem-solving abilities.
Effective interpersonal and professional communication skills.
Strong organizational, time management and project management skills and multi-tasking abilities.
Demonstrated working knowledge of any editing claims system, QNXT is preferred.
Must be PC literate; MS Office skills (Word, Excel, PowerPoint).
You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California.
Employee-only coverage in the the HMO plans are currently available at no cost and dependent coverage is heavily subsidized by SFHP.
You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
Employee vision care coverage is available at no cost.
Time Off: 23 days of Paid Time Off and 12 observed company holidays.
Opportunities for tuition reimbursement, professional license/membership.
Established in 1994, 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 170,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.
SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.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.