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Claims Specialist I, South San Francisco, CA

Health Plan of San Mateo


South San Francisco, CA

January 27, 2017


The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Claims Specialist I to review and resolve claims of varying degrees of complexity within established timeframes and using appropriate program policies and procedures. The Claims Specialist I will review claims related to 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.


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

Ability to: 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.

Starting Compensation Range: Between $19.08/hour and $26.24/hour - depending on experience.

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.

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. EOE

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