Claims Examiner

$58,240 - $66,560/Yr

San Francisco Health Plan - San Francisco, CA

posted 4 months ago

Full-time - Entry Level
San Francisco, CA
251-500 employees
Ambulatory Health Care Services

About the position

The Claims Examiner at San Francisco Health Plan is responsible for processing, adjudicating, and researching claims. This role requires maintaining high standards in claims processing while staying current on procedures and assisting Claims Management with special projects. The position emphasizes accuracy and quality in handling claims, particularly within the Medi-Cal program.

Responsibilities

  • Accurate processing, adjudication, and claims research.
  • Maintain the department's claim inventory and clear edit queues by processing claims based on eligibility verification and provider contracts.
  • Utilize the QNXT claims processing module for claims processing.
  • Meet production and quality standards in claims processing and related tasks.
  • Handle call tracking tickets regarding claims status, billing, payment issues, and disputes.
  • Stay informed about changes in Medi-Cal regulations and current processing procedures.
  • Foster an inclusive environment to better serve staff, members, and providers.

Requirements

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

Benefits

  • Health Benefits including medical, dental, and vision plans.
  • Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
  • 23 days of Paid Time Off (PTO) and 13 paid holidays.
  • Opportunities for tuition reimbursement and professional license/membership.
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