Claims Examiners review and resolve claims within established timeframes using the appropriate program policies and procedures. This ensures that Health Plan of San Mateo (HPSM), a community-based nonprofit, accurately processes the claims submitted by our network providers for our more than 160,000 members.

There are three classification levels for the Claims Examiner position (I, II and III) that correspond to candidates’ years of experience, level of knowledge and demonstrable skills. Candidates of every experience level are encouraged to apply, and HPSM will determine which position level applicants qualify for.

One of the great perks of working for HPSM is that we give our employees a range of options for where and when they work to accommodate each individual’s personal workstyle and lifestyle. For example, while most staff work exclusively from home, some choose to work fully onsite or hybrid in our well-appointed South San Francisco office. Employees can also opt for a 4/10 flex schedule with three-day weekends, or work eight-hour shifts with start times ranging from 6:00 to 8:00 a.m.

Position overview

• Review all types of complex claims edits (including medical, dental, inpatient/outpatient, supplies and DME) for accuracy in a timely manner
• Research claims and respond to external parties’ requests for information
• Appropriately resolve each claim (for example: by paying, denying, requesting adjustment, referring for higher level review or requesting clarification from providers of pricing, documentation, coding or benefits)

Key skills

• Conduct claims reviews according to policies, procedures, the Claims Manual and other sources
• Train and audit claims/reports reviewed by Claims Examiners I and serve as a subject matter expert on claims issues for other departments
• Monitor own productivity using automated reporting tools
• Advise supervisor of potential ways to improve departmental efficiency, productivity, quality, accuracy and compliance
• Create and develop departmental memos, processes and tools

Requirements

These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply.

Education

• High school diploma, GED or equivalent

Experience

• Minimum of two years’ medical and/or dental claims processing experience

Knowledge of:

• Medi-Cal and Medicare benefits and billing requirements
• Medical terminology and standard claim forms
• CPT, HCPCs, Rev, Codes and ICD-10 coding

Ability to:

• Accurately perform alpha-numeric data entry
• Work cooperatively with others as part of a team
• Communicate effectively both verbally and in writing
• Organize workflow but adjust quickly to changing departmental priorities as needed
• Follow internal policies/procedures and regulatory requirements

Salary and benefits

The starting salary range is dependent on experience and maintaining equity within the organization. The starting hourly rate range for this position is: $20.69 - $31.66.

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 on top of salary)
• 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

Health Plan of San Mateo (HPSM) is a local community-based health plan that manages the health care of over 160,000 low-income people San Mateo County, including all its Medi-Cal eligible residents. HPSM is proud to be an Equal Opportunity Employer and an affirmative action employer. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status