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Claims Quality Data Analyst, South San Francisco, CA

Health Plan of San Mateo

Data Analyst

South San Francisco, CA

January 6, 2018


The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Claims Quality Data Analyst. Under the general direction of the Claims Director, the Claims Data Quality Analyst evaluates HPSM’s claims encounter data and identifies errors created by operational gaps including those related to claims processing, eligibility records and provider submission errors to improve HPSM’s overall encounter reconciliation process and ensure compliance with state and federal billing requirements. This role works closely with other internal departments including Information Technology, Medicare Risk Adjustment, Provider Services and Member Services.

The essential duties and responsibilities will include the following:

  • Conduct ongoing root cause analyses to identify and remediate denials associated with encounter data submissions to state and federal regulators.
  • Coordinate the correction of claims related errors and initiate resubmissions.
  • Coordinate the resolution of non-claim related errors through collaborating with the appropriate department.
  • Propose and implement solutions for future prevention and continuous process improvement.
  • Develop and maintain reference material repository to track internal system and process modifications related to encounter data.
  • Lead or participate in special projects as needed.
  • Work in conjunction with HPSM’s IT Claims Configuration and Programming teams to ensure the claims system conforms to standard billing policy.
  • Identify and present opportunities for system enhancements and educational opportunities for both internal and external partners and staff.
  • As a contributing member of encounters-related workgroups, formally and informally collaborate, provide operational support, and coordinate work efforts with internal departments to improve encounter data quality and processes.
  • Develop processes to support operational strategy for encounter processes.
  • Keep abreast of healthcare industry best practices, system capabilities and managed care regulatory requirements. Mapping of local Medi-Cal specific billing codes to nationally recognized equivalents.
  • Provide support as a coding resource to the Claims Department for ICD-10-CM, CPT and HCPCS code set.


Education and Experience:

  • Five years of work experience in a health care or managed care environment with an emphasis on coding, auditing or claims related system configuration.
  • Bachelor's Degree preferred.
  • Certified Professional Coder (CPC) certification preferred.

Knowledge of:

  • Claims coding including ICD-10-CM, CPT, HCPCS and revenue codes.
  • Medicare and Medi-Cal billing requirements.
  • Entire claims billing cycle including claim submission, processing and payment.
  • Billing requirements for the both professional and institutional claims
  • Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
  • Local, State and Federal laws, rules, and regulations pertaining to claims payment
  • 837 institutional and professional file structure is a plus

Ability to:

  • Apply CMS and Medi-Cal billing guidelines.
  • Learn and operate within the organization’s claims and data systems
  • Manage projects; prioritize/organize workload
  • Work as part of a team and support team decisions.
  • Communicate effectively, both verbally and in writing.
  • Demonstrate strong analytical and problem solving skills
  • Prioritize tasks and meet deadlines
  • Adapt to changes in requirements/priorities for daily and specialized tasks
  • Identify and recommend opportunities to improve existing processes.

Starting Compensation Range: - Depends 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

Submissions without a Cover Letter and Salary Expectations may not be considered.

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