Claims Examiner

Job Locations US-CA-San Francisco
Job ID
Regular Full-Time



Established in 1997, San Francisco Health Plan (SFHP) is a an award winning,  managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. San Francisco Health Plan is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 142,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.




The incumbent in this position is responsible for the claims processing, adjudication and claim research, where applicable. Must meet qualitative and quantitative standards established for this position. Assist Claims Management with audits and special projects as needed.


  • Review and adjudicate claims (paper and EDI) and resolve claim edits, using claims desk level and operational reference materials.
  • Utilize the QNXT claims processing module in an effective and efficient manner to process claims
  • Make appropriate decisions regarding the clearing of claim edits and payment of claims.
  • Meet production and quality standards when processing claims and performing tasks.
  • Complete the manual pricing of claims according to provider contracts and other claims pricing references.
  • Interpret medical group and provider contracts to determine claims payment methodologies.
  • Complete more complex claims processing tasks including: claim adjustments, coordinating benefits with secondary carrier, claim reversals, etc.
  • Handle smaller scale projects in claims from start to finish.
  • Work with Claims Management to resolve difficult or complex transactions and to identify system and/or training-related opportunities that will assist in operating results improvement.
  • Respond to first and second level provider inquiries, claim status calls and faxes from provider.



  • AA degree and 2 years related experience or equivalent combination of education and experience.
  • Hands-on working knowledge and background using claims processing system(s).
  • A minimum of 2 years prior work experience in claims operations environment and health care insurance business, preferably with focus on Medi-Cal claims.
  • Knowledge of CPT/HCPCS, ICD-9 coding, medical terminology and managed care principles.



  • Must be PC literate; MS Office skills (Word, Excel, PowerPoint).
  • Regularly required to operate standard office equipment (personal computer, photocopy machine, fax machine, etc.)
  • Ability to work on a computer up to 7 hours a day.
  • Regularly required to sit for long periods of time, and occasionally stand and walk.
  • Regularly required to use hands to operate computer and other office equipment.
  • Close vision required for computer usage.

NOTE: This description is not intended to be construed as an exhaustive list of duties, responsibilities or requirements for the position. This position may change or assume additional duties at any time. The employee may be requested to perform different or additional duties as assigned.


San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.


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