Reporting to the Supervisor of Quality Assurance, the Quality Assurance Analyst performs intermediate and advanced level daily quality assurance reviews to ensure and report on the accuracy of claims processing end-to-end and other important business processes.

Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.

Salary: $90,000 to $109,000 annual

WHAT YOU WILL DO:

• Audit daily processed claims and PDRs through random selection based on set criteria.
• Exceed audit productivity and quality standards to maintain the integrity of the claims adjudication process.
• Maintain and report claim samples, ensuring that all claims within sample are audited.
• Determine error sources and accurate entry of claim audits into the Quality Database daily.
• Atten audit appeal meetings and present audit findings to partners.
• Interpret and understand Medi-Cal and Medicare contracts with knowledge of DHCS/DMHC/CMS guidelines and regulations.
• Ensure the accurate application of managed care agreements as they apply to product lines.
• Ensure pricing arrangements have been applied.
• Attend and actively participate in Quality Assurance Team meetings.
• Perform quality audits of other operational processes (i.e. , data entry accuracy, etc.).
• Provide ad hoc consultation to Claims department, to include providing advice on claim processing/documentation and Provider Dispute Resolution (PDR) processing/documentation, and UAT assistance for Claims processes.

WHAT YOU WILL BRING:

• Bachelor’s Degree with an emphasis in health care or business preferred, or equivalent business experience.
• Five years of health care auditing experience or demonstrated proficiency as Claims Analyst or QA Specialist
• Knowledge of Medi-Cal and Medicare fee schedules
• Knowledge of health care and managed care industry terms, including HCPCS, CPT, ICD-10, APR/DRG, Medical Terminology.
• Experience with medical insurance billing and payment process; including the intricacies of CMS1500 and UB04 forms; the use of the remittance advices to explain payment details to providers and related partners

WHAT WE OFFER:

• Health Benefits
  • Medical: You’ll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
  • Dental: You’ll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
  • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
• Retirement – Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off – 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.

ABOUT SFHP:

Established in 1997, San Francisco Health Plan (SFHP) is 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. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.

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