Claims Specialist

Reporting to Supervisor, Claims Processing, the Claims Specialist is responsible for complex claims processing, Provider Dispute Resolution (PDR) processing, recoupments, claims adjustments, and research. Must meet qualitative and quantitative standards established for this position. You will maintain Claims Department's inventory, handle claims trouble shooter reports, and respond to first level escalations. Also, this position must stay informed about Claims and PDR processing procedures, and assist Claims Management on audits, project user acceptance tests, and special projects.

Please note that while SFHP supports a hybrid work environment, the Claims Specialist 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

WHAT YOU WILL DO:

• Keep the department's claim and PDR inventory current and clear edit queues by processing claims and PDRs according to regulatory requirements, eligibility requirements, and program benefits and provider contracts.
• Process claims recoupments when needed.
• Conform to established standards of performance for quality and timeliness.
• Correctly match authorizations and PDRs to claims.
• Coordinate benefits/other health coverage.
• Use the QNXT claims processing module in an effective and efficient manner to process claims.
• Use the JIVA system for PDR processing in an effective and efficient manner to process disputes.
• Interpret medical group and provider contracts to determine claims payment methodologies.
• Review and adjudicate claims (paper and EDI) and resolve claim edits and PDRs, using claims desk top procedures and operational reference materials.
• Review claims for correct provider coding information and appropriateness of reported services and billing practices.
• Review claims for necessity, limitations, and exclusions based on claims policies and procedures.
• Review claims/PDRs for missing or incomplete information; request additional information needed to complete PDR and adjudication of claims.
• Help with correct claims errors and reprocess claims.
• Make informed decisions regarding the clearing of claim edits and payment of claims.
• Document claims to support payments or decisions.
• Process retro-terminations and Claims trouble shooter reports
• Complete more complex claims processing tasks including claim adjustments, coordinating benefits with secondary carrier, claim reversals, etc.
• Handle projects of smaller scale in claims from start to finish.
• Perform user acceptance tests for projects.
• Work with Claims management to resolve difficult or complex transactions and identify system and/or training-related opportunities to enhance Claims operations.
• Respond to first level provider inquiries, call tracking tickets, misdirected claims, and faxes from providers.
• Handle provider calls and call tracking tickets promptly and courteously regarding claims status, billing and payment issues, disputes, etc...
• Provider Dispute Resolutions:
  
  
  
  • Respond to provider disputes.
  • Research provider disputes to ensure appropriate resolutions.
  • Maintain and update the Provider Dispute Log.
  • Help to update configuration in JIVA for Claims Department needs.
  • Complete claims processing adjustments to resolve issues.
  • Create letters according to the regulatory requirements and timelines.
  
  
  
  
• Maintain and update current desk procedures and reference materials.
• Identify and report billing errors and collaborate with other departments to enhance processes.
• Recognize system problems and work with ITS/BST to resolve.
• Stay informed about the changes in regulations, program policies, and current processing procedures.
• Be a Subject Matter Expert for claims and PDRs related meetings or workgroups.

WHAT YOU WILL BRING:

• 3 years prior work experience in claims operations environment in health care insurance business, preferably with focus on Medi-Cal claims
• Knowledge of managed care and Medi-Cal reimbursement.
• Hands-on working knowledge and background using claims processing system such as QNXT.
• Demonstrated depth of experience in medical claims procedures, processes, governing rules, and all aspects of claims adjudication including solid knowledge of CPT/HCPCS, ICD-10 claims coding, and medical terminology.
• Knowledge of Claims Editing Software preferred.
• Knowledge of Medi-Cal benefits, claims processing, and claims regulatory requirements.
• Basic knowledge of PDR and recoupment processing.
• Process multiple types of claims and identify claim errors.
• A high school diploma or equivalent; college degree preferred.

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.

#LI-Hybrid

(Hybrid remote/in-office)

PI279281093