San Francisco Health Plan

  • Claims Analyst

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




    The Claims Analyst is accountable for accurate and timely adjudication of claims transactions utilizing edit queues, provider inquiries, refunds, as well as researching and analyzing to determine root causes to streamline the Claims Department’s processes. This position is responsible for recoveries, stop loss reinsurance, reimbursements and processing claims when needed. As part of the team, the analyst must keep current on claim processing procedures and produce a quality and timely work product.



    • Analyze claim issues from identification to resolution. This entails: Identifying claims processing anomalies and offer solutions to address; completing root cause analysis for claims that are not processed accurately; identifying system or process deficiencies and offer suggestions for corrective actions; participating and providing feedback on claims system configuration testing; researching claim errors or inaccurate claim payments and identifying fixes.
    • Through analysis and process improvement, assist with accuracy, timely research, and adjudication of claim recoveries and overpayments, including: Coordination of benefits/other health coverage, overpayments (provider refunds) and reimbursement requests, refunds and retro-terminations.
    • Lead distinction between complex and non-routine claims processing by utilizing a variety of claims pricing tools for complex manual pricing of claims, interpret complex provider contracts to determine claims payments.
    • Represent the claims department as a subject matter expert and provide input to department and cross functional meetings.
    • Conform to established standards of performance for quality and timeliness.
    • When needed, keep the department’s claim inventory current and clear edit queues by process claims according to verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing.
    • Review claims for missing or incomplete information; requesting additional information needed to complete adjudication of claims.
    • Review claims for necessity, limitations and exclusions based on claims policies and procedures and document in claims notes to support payments or decisions.
    • Determining the level of reimbursement based on established criteria and defined provisions.
    • Manage stop loss/reinsurance.
    • Determine and process overpayments (provider refunds) and reimbursement requests.
    • Ensure that the remit message provides the necessary explanation of payment for the provider
    • Reprocess /adjust claims when necessary.
    • Assist with service to Providers; handle provider calls promptly and courteously regarding claims status, billing and payment issues, disputes, etc.
    • Help with Provider Dispute Resolutions:
      • Responding to provider disputes in a timely and accurate manner.
      • Researching provider disputes to ensure appropriate resolutions.
      • Adjudicating claims that are over-turned thru the PDR process
      • Maintaining and updating the Provider Dispute Log.
      • Notifying manager of delay reasons that may affect timeliness of processing.
    • Work directly with provider groups and Provider Relations to resolve complex claims processing problems/issues.
    • Manage special projects within the department such as coordinating audit request
    • Maintain current desk level procedures for claims processing
    • Create an up-to-date inventory and log and monthly recovery reports where statistics are required for further analysis and monitoring by management personnel.
    • Document efforts to collect reimbursement.
    • Identifying trends in recoveries that require management intervention
    • Recognizing and documenting system issues, and working with manager and ITS to resolve
    • Keeping abreast of the changes in Medi-Cal regulations, program policies and current processing procedures.
    • Work with the Claims team to ensure consistent and accurate adjudication.



    • Minimum of 5 years prior work experience in claims operations environment in health care insurance business with 2 years working as an analyst
    • High school diploma; college degree preferred
    • Demonstrated depth of knowledge and experience in medical claims procedures, processes, governing rules and all aspects of claims adjudication including solid knowledge of CPT/HCPCS, ICD-9 claims coding and medical terminology
    • Knowledge of managed care and Medi-Cal reimbursement
    • Solid understanding of standard claims processing systems and claims data analysis
    • Excellent verbal and written communication skills
    • Strong MS Office skills (Word, Excel, PowerPoint)
    • Hands-on working knowledge and background using claims processing system(s). QNXT application (V. 4.81 or later) experience preferred
    • Detail oriented with problem-solving abilities
    • Strong organization, time management and project management skills and multi-tasking abilities
    • Excellent qualitative and quantitative abilities
    • Ability to handle detailed work, work with varying types of data and maintain confidentiality



    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 145,000+ 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.

    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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