Claims Examiner

Join our team as a Claims Examiner at Health Plan of San Mateo (HPSM), where you’ll play a key role in reviewing and resolving claims for over 160,000 members. In this position, you’ll tackle everything from medical and dental claims to inpatient/outpatient, supplies, and DME, all while ensuring they’re processed accurately and within established timeframes. You’ll research claims, communicate with providers, and resolve issues by making decisions to pay, deny, or adjust claims. Additionally, you’ll monitor your productivity, contribute to process improvements, and serve as a subject matter expert for other departments to ensure the highest quality and compliance standards.

Key Responsibilities

• Review and resolve complex claims (medical, dental, inpatient/outpatient, supplies, and DME) for accuracy in a timely manner.
• Research claims and respond to external inquiries, ensuring accurate information is provided.
• Resolve claims by paying, denying, adjusting, or escalating as needed, in line with program policies and procedures.
• Train and audit Claims Examiners I and serve as a subject matter expert for claims-related issues across departments.
• Monitor personal productivity, suggest improvements for departmental efficiency, and assist in creating process improvements 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 & Experience: High school diploma, GED, or equivalent required. At least two years of medical and/or dental claims processing experience preferred.
• Knowledge: Familiarity with Medi-Cal and Medicare benefits, billing requirements, medical terminology, and standard claim forms (CPT, HCPCS, ICD-10 coding).
• Skills & Abilities: Strong alpha-numeric data entry skills, effective communication abilities (both verbal and written), and the ability to work cooperatively as part of a team.
• Other Requirements: Ability to organize workflow and adapt quickly to changing departmental priorities while following internal policies and regulatory requirements.

Outstanding Benefits Package Includes:

• 100% HPSM-paid medical, dental, and vision coverage for employees (dependents' premiums are 90% covered by HPSM).
• Fully funded life insurance, AD&D, and long-term disability (LTD) coverage.
• Generous retirement plan with HPSM contributing an equivalent to 10% of your annual salary.
• Ample paid time off: 12 holidays, 12 sick days, and vacation starting at 16 days per year.
• Tuition reimbursement to support your professional growth.
• A robust employee wellness program to promote your well-being.

It is HPSM's policy to provide equal employment opportunity 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.