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Claims Auditor I, South San Francisco, CA


Health Plan of San Mateo

Professional

South San Francisco, CA

October 3, 2019


CLAIMS AUDITOR I

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Claims Auditor I to perform concurrent and retrospective review of claims processed by all areas of the Claims Department. Train and/or retrain staff on policies and procedures related to claims processing; and log, track, and report all audit activity and provide information to the Claims Managers and others as required.

The essential duties and responsibilities will include the following:

  • Perform an appropriate number of audits on a timely basis, based on retrospective accuracy percentages of each incumbent.
  • Perform concurrent, retrospective and preventive review of claims processed by all levels of Examiners, claims processes, and claims transmitted via OCR.
  • Handle responses/appeals to audit findings
  • Assist in the review and maintenance of auditing guidelines, including the audit tracking database and make recommendations to the Claims Managers to increase the accuracy of claims processed
  • Log, track, and report all audit and productivity results and provide information to the Claims Managers and others as needed.
  • Recommend areas in need of additional training and/or close oversight based on the trending and analysis of audit results.
  • Handle urgent and/or sensitive issues, including PCIs, projects, and escalated calls.
  • Maintain working knowledge of policies and procedures for standard work processes in the Claims Department.
  • Process claims on an occasional basis to maintain skills
  • Perform other duties as assigned

Requirements

Education and Experience: Two (2) years of experience in health claims processing/adjudication. A college degree in a health or business related field is preferred.

Knowledge of: Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint. Medicare and Medi-Cal programs

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. Work in a fast-paced, highly pressured, and changing environment. Analyze/evaluate information. Interpret policies and procedures. Produce basic logs and reports. Interact effectively with others and be a team player. Communicate efficiently orally and in writing. Organize workload. Work independently, using sound judgment

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: careers@hpsm.org 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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