Reporting to Supervisor, Claims, the Senior Claims Analyst, is responsible for accurate adjudication of claims transactions using edit queues, provider inquiries, and refunds, and researching to find causes of issues and refine the Claims Department's processes. You must stay informed about Claims processing procedures and produce a quality work product.

Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.

Salary: $99,000 - $115,000 per year

WHAT YOU WILL DO:

• Analyze claim issues from identification to resolution. This requires identify claims processing anomalies and offer solutions; complete root cause analysis for claims that are not processed correctly; identify system or process deficiencies and offer suggestions for corrective actions; participate and provide feedback on claims system configuration testing; and research on claim errors or inaccurate claim payments and provide solutions.
• Assist to improve accuracy, research claim issues, and correct claims for over/under payments. Coordinate benefits with other health coverage, and process refunds and retro-terminations.
• Process complex and non-routine claims by using a variety of claims pricing tools for complex manual pricing of claims. Interpret complex provider contracts to determine claims payments.
• Represent the Claims Department as a subject matter expert and provide input in inter-departmental meetings.
• Conform to established standards of performance for quality.
• Keep the department's claim inventory current and clear edit queues by processing claims according to verification of eligibility, and interpretation of program benefits and provider contracts to include manual pricing.
• Review claims for missing or incomplete information. Request additional information needed to complete adjudication of claims.
• Determine the level of reimbursement based on established criteria and defined provisions.
• Work directly with provider groups and Provider Relations to resolve complex claims processing issues.
• Manage special projects within the department such as coordinating audit request.
• Determine and process overpayments (provider refunds) and reimbursement requests.
• Ensure that the remit message provides the necessary explanation of payment for the provider.
• Reprocess /adjust claims.
• Help with services to Providers:
  • Handle provider calls promptly regarding claims status, billing and payment issues, disputes.
  • Help with Provider Dispute Resolutions.
  • Respond to provider disputes.
  • Research on provider disputes to ensure appropriate resolutions.
  • Adjudicate claims that are overturned through the PDR process.
  • Maintain the Provider Dispute Log and update, when needed.
  • Notify manager of reasons of delay that may affect the timeliness of processing.
• Maintain current desk level procedures for claims processing.
• Create training materials and provide training to the team.
• Create an up-to-date inventory log and monthly recovery reports where statistics are required for further analysis and monitoring by management personnel.
• Document efforts to collect reimbursement.
• Identify trends in recoveries that require management intervention.
• Recognize and document system issues, and work with manager and ITS to resolve.
• Stay informed about the changes in Medi-Cal regulations, program policies, and current processing procedures.
• Work with the Claims team to ensure accurate adjudication.
• Review QA Findings.
• Review and resolve Provider Dispute Resolutions (PDR) by assessing disputes in the PDR system.
• Maintain Claim Department's documentation, desktop procedures and process maps, to ensure they are current.
• Help with preparation for internal and state audits.

WHAT YOU WILL BRING:

• 5 years of prior work experience in claims operations environment in health care insurance business with 2 years of work as an analyst.
• Demonstrated depth of experience in medical claims procedures, processes, governing rules and all aspects of claims adjudication including solid knowledge of CPT/HCPCS, ICD-9 claims coding and medical terminology.
• Experience with standard claims processing systems and claims data analysis.
• Hands-on working knowledge and background using claims processing system(s). QNXT application (V. 4.81 or later) experience.
• A high school diploma with a college degree

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)