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Claims Examiner, South San Francisco, CA

Health Plan of San Mateo


South San Francisco, CA

June 26, 2019


The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Claims Examiner II. 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, facility (inpatient and outpatient), supplies and DME claims that require intervention for pricing, documentation requirements, appropriate coding and benefit determinations.

The essential duties and responsibilities will include the following:

  • 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 in order to complete the required number of weekly reviews deemed appropriate for this position.
  • Coordinate the collection of missing claims information from providers.
  • Provide training, backup training, occasional auditing and review of claims and reports worked by Claims Examiner’s.
  • Provide accurate and timely information regarding daily production, claim’s issues, training and other reasons for time off production.
  • Monitor own performance via production and auditing tools and reports
  • Communicate issues with Manager and Claims Auditor; make recommendations on claims issues.
  • 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.


Education and Experience: High School diploma, GED or equivalent required. Two (2) years equivalent experience as a Claims Examiner I with successful completion of all duties.

Knowledge of: Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint. Medical billing and terminology. Medi-Cal and Medicare programs. Procedure and diagnostic coding.

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.

Compensation and Benefits

Starting Compensation Range: - Depending on Experience

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage. Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits. Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.

How to Apply

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. The Health Plan of San Mateo is proud to be an Equal Opportunity Employer and encourages minority candidates of all backgrounds to apply.

Submissions without a Cover Letter and Salary Expectations may not be considered.

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