Medical Claims - Policy Specialist

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Medical Claims Policy Specialist to monitor, develop, test, and document claim configuration changes as well as related procedural changes that are directed by state, federal, and internal policy.   Communicate changes with HPSM staff and provider community, as well as provide support in the testing of all system enhancements and internal configuration updates to ensure accurate adjudication and adherence with state and federal guidelines.

The essential duties and responsibilities will include the following: 

• Research, analyze, and recommend claims system configuration modifications.
• Develop and maintain updates of all internal and external documentation related to Claims configuration and policy changes.
• Develop provider education/training materials as related to configuration and policy changes.
• Continually review/audit system configuration rules to ensure accurate application of policies.
• Keep abreast of healthcare industry best practices, system capabilities and managed care regulatory requirements.
• Resolve provider disputes and research and resolve claim issues for providers and internal staff.
• Coordinate and manage training associated with system changes.
• Lead or participate in special projects as needed.
• Professionally represent HPSM at internal and external meetings
• Perform other duties as assigned

Requirements

Education and Experience: High School Diploma/GED required; Bachelor's preferred.  Five (5) years’ experience in health care or managed care with an emphasis on coding and billing policy.  

Knowledge of:  Medical claims processes and procedures.  General personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint

Ability to: Communicate effectively with strong emphasis on written communication; Demonstrated ability to successfully manage multiple projects simultaneously; interpret government rules and regulations; Use initiative; work independently; make sound independent judgments; Prepare concise reports and recommendations, and Interact well with a variety of people and work effectively as part of a cross functional team.

Compensation & Benefits

Starting Compensation Range:  Depends on Experience.

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage.  Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits.  Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.