processing, adjudication, claims research and claims inquiries escalated from Customer Service. You must meet qualitative and quantitative standards established for this position and 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 as needed.

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

WHAT YOU WILL DO:

• 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 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 resolves claim edits, using claims desktop procedures and reference materials.
• Reviews 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.
• Reprocesses and adjusts claims when needed.
• Process retro-terminations.
• Processes 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 contributes to the enhancement of operating results.
• Perform other responsibilities and special projects as assigned.
• Handle provider call tracking tickets, claims status, billing, and payment issues promptly.

WHAT YOU WILL BRING:

• 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.
• Knowledge of CPT/HCPCS, ICD-10 coding, medical terminology, and managed care principles.
• A high school diploma or equivalent
• Knowledge of Claims Editing Software 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)