San Francisco Health Plan

  • Claims Examiner

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



    The Claims Examiner is responsible for the administrative functions of the Claims Department and for processing Level I claims



    • Process provider dispute resolutions, incoming and outgoing mail, mail rejects, and misdirected claims
    • Filing and OCR scanning and validation of claims and other documents
    • Department equipment vendor relations and maintenance
    • Adjudication of Level I electronic claims, including:
      • Reviews and processes claims according to completeness and validity based on verification of eligibility and interpretation of program benefits
      • Determines the level of reimbursement based on established criteria and additional provisions
      • Reviews claims for correct provider coding information regarding appropriateness of reported services and billing practices
      • Processes all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner
      • Reviews claims for necessity, limitations and exclusions based on claims policies and procedures
      • Documents claims to support payments or decisions
      • Reviews claims for missing or incomplete information




    • High school diploma or equivalent required
    • 2 years prior work experience in claims operations environment and health care insurance business, preferably with focus on Medi-Cal claims desired
    • Excellent data entry skills required
    • Knowledge in areas such as:
      • Medi-Cal billing and payment guidelines and other state regulatory agencies (CCS, CHDP, DHS).
      • Managed care industry
      • Medical terminology
      • Standard claim forms and physician billing coding
      • Ability to read/apply standard reference claims materials
      • MS Office skills (Word, Excel, PowerPoint)

    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 140,000+ 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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