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About Us

Claims Quality Assurance Analyst

San Francisco Health Plan has an opening for a Claims Quality Assurance Analyst.  This position is responsible for the conducting financial, operational, contractual and compliance audits, appraising both operations and systems of internal control, performance and policy compliance.  Incumbent uses audit results to conducts contractual and system analyses for determination of performance enhancement, cost reduction, system automation and auto-adjudication opportunities.

Responsibilities:   

  • Conducts comprehensive quality audits to identify system or claim adjudication deficiencies to monitor the effectiveness of business processes and system performance.  Analyze results and prepare recommendations to Management for improvements.
  • Work with Management, IS operations staff and Claims staff to identify, develop, improve and/or implement improvements or enhancements to improve claim operational results.
  • Audit approval listings and medical group claim adjudication bi-monthly and provide feedback to Manager, IS operations and claims staff. 
  • Analyze and trend correspondence, i.e., refunds, mailbacks and provider disputes.
  • Develop and implement other quality improvement strategies.  Act as subject matter expert for quality assurance area. 

Knowledge, Skills and Abilities:

Knowledge of:

  • Standard claims processing procedures
  • Claims auditing experience
  • Claims policies, procedures and claim-related programs
  • Contract implementation and its processes

Ability to:

  • Organize work effectively
  • Work with external departments and vendors
  • Conduct analyses and prepare reports for management

Requirements/Qualifications: 

  • High school diploma or equivalent required. 
  • Ability to operate PC based software programs or automated database management systems preferred. 
  • Must type 35 wpm and perform 10-key by touch. 
  • Familiar with Medi-Cal billing guidelines and other state regulatory agencies (CCS, CHDP, DHS). 
  • Strong communication skills with strong analytical and problem solving skills. 
  • Ability to self-manage in a detail oriented environment. 
  • Knowledge required; managed care industry, medical terminology; standard claim forms and physician billing coding; ability to read/apply standard reference materials (CPT, ICD-9, HCPCS, RVS); coordination of benefits. 
  • Good organization and prioritization skills, outstanding in time management. 
  • Excellent Audit and data analysis required. 
  • 3-4 years prior experience in health insurance claims processing.

Interested candidates should apply on line at:
https://home.eease.com/recruit/?id=40162 

Please reference job code CASFHPADP408. If the link does not work (this happens  from time to time, depending on your web browser), please cut and paste the above web address into your web browser.

San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V