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Medical Claims Review Nurse, South San Francisco, CA

Health Plan of San Mateo


South San Francisco, CA

June 7, 2017


The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Medical Claims Review Nurse to perform the following essential duties & responsibilities:

  • Review retrospective authorization requests/claims documentation within specified timeframes.
  • Review authorization requests/claims for out-of-network inpatient facilities.
  • Clinically validate the medical appropriateness and coding accuracy of services rendered in an inpatient setting.
  • Accurately document audit determinations within the audit tracking system by creating a rationale narrative.
  • As needed, support findings during the appeals process.
  • Serve as a clinical resource; provide clinical expertise and clinical guidance to the claims team.
  • Work collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential abuse.
  • Monitor, track, and report on all work conducted.
  • Review targeted claims i.e. high dollar/potential for abuse.
  • Refer members to care coordination and case management as the need is identified during the review process.
  • Maintain collaborative and cooperative relationships with other HPSM departments.
  • Utilize appropriate resources to guide review decisions and document decisions clearly and concisely.


License and Certification: A valid, unrestricted California license as a Registered Nurse.

Education and Experience: Five (5) years clinical nursing experience preferred. Experience with utilization management retrospective review and coding methodologies within a managed care environment is preferred. A Bachelor’s degree in nursing or a related health services field is a plus.

Knowledge of: CPT, ICD-9, and DRG coding principles. Medicare and Medi-Cal coverage requirements and regulatory guidelines. Utilize Access, Microsoft Office programs; perform internet research.

Ability to: Ensure medical appropriateness and effective utilization of health care resources. Maintain timely compliance with all UM and Claims regulatory mandates. Ensure provider conformance to HPSM UM and Claims guidelines. Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the general public. Communicate effectively, both verbally and in writing, with individuals from varying cultural and ethnic backgrounds. Effectively utilize computer and appropriate software and interact, as needed, with IT staff.

Starting Compensation Range: Between $40.86/hour - $51.82/hour - depending on experience.

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.

Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: or via fax: (650) 616-8039. File by: Continuous until filled. EOE

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