Health Plan of San Mateo - South San Francisco, CA

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The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a Claims Examiner II who will perform independent and accurate entry and processing of difficult and complex claim types, run reports for review, and perform adjustments as needed. Also provide training and guidance to Claims Examiners I.

Primary duties

Independently processes and reviews complex claims on paper or by report and determines appropriate handling for each by paying, denying, pending, adjusting, referring or forwarding claims to be sent back to the provider. Uses Policies & Procedures, Claims Manual, and other sources in order to provide the highest number of resolved claims as possible. Performs specialist projects/tasks assigned by the Claims Resources Manager and analyzes more complex claims, haste issues, provider audits, processor audits, reporting and documentation. Provides training, backup training, occasional auditing and reviews of claims and reports worked by Claims Examiners I. Performs ongoing training on all claim types, reviews audit errors and other reports, and updates and maintains reference materials. Assists in the creation and development of memos, processes and tools when needed. Provides accurate and timely information regarding daily production, claim’s issues, training and other reasons for time off production. Monitors own performance via production and auditing tools and reports. Attends team, company, and one-on-one meetings and other functions. Communicates issues with Claims Resources Manager and Claims Auditor as well as makes recommendations on claims issues. Perform other duties as assigned.


Education and Experience: Equivalent to a High School diploma and two years as Claims Examiner I with successful completion of all duties.

Knowledge of: Medical billing and terminology. Personal computer and experience with Microsoft Excel and Word Medi-Cal and Medicare programs. Procedure and diagnostic coding.

Ability to: Perform alpha-numeric data entry proficiently. Perform with attention to detail. Organize and prioritize daily work; complete multiple tasks within established time frames. Communicate effectively, verbally and in writing. Maintain accurate records. Use clear notes or remarks to document relevant information. Exercise good judgment within scope of authority. Handle confidential issues with tact and diplomacy.

BENEFITS INFORMATION: Excellent benefits package offered including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; 457 Plan in lieu of social security (7.5% of salary/HPSM paid); retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.

APPLICATION PROCESS: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 701 Gateway Blvd., Suite 400, South San Francisco, CA94080. Email: Fax: 650-616-8039 File by: Continuous until filled. EOE

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