Claims Examiner II

Health Plan of San Mateo (HPSM); South San Francisco (CA); On-site; USD 10,000 - 60,000; Full time

Job summary

A leading health care organization is seeking a Claims Examiner II to review and adjudicate claims, ensuring compliance with established policies. This full-time position offers competitive pay, comprehensive benefits, and an opportunity to contribute to the health services sector, requiring attention to detail and effective communication skills.

Benefits

Health, dental, and vision coverage

Retirement plan with employer contributions

12 paid holidays and sick days

Employee wellness program

Tuition reimbursement

Qualifications

• High School diploma, GED or equivalent required.
• Two years of experience processing medical and/or dental claims.
• Knowledge of Medi-Cal and Medicare programs.

Responsibilities

• Review and resolve claims with varying degrees of complexity.
• Provide peer-to-peer training and monitor performance.
• Communicate issues with management and make recommendations.

Skills

Medical billing

Medical terminology

Procedure coding

Diagnostic coding

Data entry

Communication skills

Education

High School diploma or equivalent

Tools

Microsoft Office Suite

Job description

Join to apply for the Claims Examiner II role at Health Plan of San Mateo (HPSM)

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Join to apply for the Claims Examiner II role at Health Plan of San Mateo (HPSM)

Requirements

Under general supervision, the Claims Examiner II reviews and resolves a caseload of claims with varying degrees of complexity within established timeframes and using appropriate program policies and procedures. Reviews may include medical, dental, inpatient and/or DME claims that require intervention for pricing, documentation requirements, appropriate coding and benefit determinations. Position overview Essential Functions:

• Independently review claims edits with varying degrees of complexity to determine the appropriate handling for each including paying, denying, pending, adjusting, referring or forwarding claims to be sent back to the provider
• Responsible for accurate and timely adjudication and review of claims according to HPSM guidelines.
• Use policies & procedures, claims manual and other sources to complete the required number of weekly reviews deemed appropriate for this position.
• Provide peer-to-peer training as needed.
• Provide accurate and timely information regarding daily production, claim issues, training and other reasons for time off production.
• Monitor own performance via production and auditing tools and reports.
• Communicate issues with the Manager and Claims Auditor; make recommendations on claims issues and opportunities for improvement. Secondary Functions:
• Attend team, company, and one-on-one meetings and other functions.
• Communicate issues with Manager and Claims Auditor; make recommendations on claims issues.
• Perform other duties as assigned. Requirements These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply. Education and experience are equivalent to:
• High School diploma, GED or equivalent required.
• Two (2) years’ of experience processing medical and/ or dental claims. Knowledge of:
• Medical billing and terminology.
• Medi-Cal and Medicare programs.
• Procedure and diagnostic coding.
• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint. Ability to:
• Work cooperatively with others.
• Work as part of a team and support team decisions.
• Communicate effectively, both verbally and in writing.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• 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.
• NCCI Edits experience a plus. Salary and benefits The starting salary range is $23.44 - $29.65 per hour, depending on the candidate’s work experience. Excellent benefits package includes:
• HPSM-paid premiums for employee’s medical, dental and vision coverage (employee pays 10% of each dependent’s premiums)
• Fully paid life, AD&D and LTD insurance
• Retirement plan (HPSM contributes equivalent of 10% of annual compensation)
• 12 paid holidays a year, 12 paid sick days a year and paid vacation starting at 16 days a year
• Employee wellness program It is HPSM's policy to provide equal employment opportunities for all applicants and employees.
  
  

Requirements

Under general supervision, the Claims Examiner II reviews and resolves a caseload of claims with varying degrees of complexity within established timeframes and using appropriate program policies and procedures. Reviews may include medical, dental, inpatient and/or DME claims that require intervention for pricing, documentation requirements, appropriate coding and benefit determinations. Position overview Essential Functions:

• Independently review claims edits with varying degrees of complexity to determine the appropriate handling for each including paying, denying, pending, adjusting, referring or forwarding claims to be sent back to the provider
• Responsible for accurate and timely adjudication and review of claims according to HPSM guidelines.
• Use policies & procedures, claims manual and other sources to complete the required number of weekly reviews deemed appropriate for this position.
• Provide peer-to-peer training as needed.
• Provide accurate and timely information regarding daily production, claim issues, training and other reasons for time off production.
• Monitor own performance via production and auditing tools and reports.
• Communicate issues with the Manager and Claims Auditor; make recommendations on claims issues and opportunities for improvement. Secondary Functions:
• Attend team, company, and one-on-one meetings and other functions.
• Communicate issues with Manager and Claims Auditor; make recommendations on claims issues.
• Perform other duties as assigned. Requirements These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply. Education and experience are equivalent to:
• High School diploma, GED or equivalent required.
• Two (2) years’ of experience processing medical and/ or dental claims. Knowledge of:
• Medical billing and terminology.
• Medi-Cal and Medicare programs.
• Procedure and diagnostic coding.
• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint. Ability to:
• Work cooperatively with others.
• Work as part of a team and support team decisions.
• Communicate effectively, both verbally and in writing.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• 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.
• NCCI Edits experience a plus. Salary and benefits The starting salary range is $23.44 - $29.65 per hour, depending on the candidate’s work experience. Excellent benefits package includes:
• HPSM-paid premiums for employee’s medical, dental and vision coverage (employee pays 10% of each dependent’s premiums)
• Fully paid life, AD&D and LTD insurance
• Retirement plan (HPSM contributes equivalent of 10% of annual compensation)
• 12 paid holidays a year, 12 paid sick days a year and paid vacation starting at 16 days a year
• Tuition reimbursement plan
• Employee wellness program It is HPSM's policy to provide equal employment opportunities for all applicants and employees.
  
  

HPSM does not unlawfully discriminate based on race, religion, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, sexual orientation, veteran status, registered domestic partner status, genetic information, gender, gender identity, gender expression, or any other characteristic protected by applicable federal, state, or local law.

HPSM also prohibits discrimination based on the perception that an applicant or employee has any of those characteristics or is associated with a person who has or is perceived to have any of those characteristics.

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Finance and Sales

• Industries

  Hospitals and Health Care

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