Director of Claims and Encounters

San Francisco Health Plan (SFHP) is a local health plan designed by and for the people of San Francisco.  Our mission is to provide affordable, quality health care to city residents - especially those who might otherwise not be able to afford it.  We currently provide health coverage to more than 52,000 members through several networks that include primary and specialty care physicians and community-based hospitals and clinics located throughout San Francisco.

San Francisco Health Plan has an opening for our Director of Claims and Encounters.  This position is responsible for the accurate and timely payment of claims for a Medi-Cal payer institution.  The Director of Claims and Encounters should be well versed in all aspects of claims operations showing increasing responsibility in the management of claims operations, preferably in a Medi-Cal managed care  payer organization.  Thorough knowledge of all pertinent State and Federal regulation is required as well as experience in operational design and change in the claims processing space.

The Director of Claims and Encounters will have current knowledge of:

1)  Coding (CPT-4, ICD-9, HCPCS, etc.)

2)  Billing methods as they apply to state and federal regulation

3)  The application of rules for the delegation and management of other claims organizations

4)  Changes to the federal and California regulations regarding the approval, payment, and processing of claims (e.g.; AB1455, etc.)

 

Responsibilities:

1.  Manages claims processing personnel, audit personnel.

2.  Interfaces with billing entities, medical management personnel, and senior management.

3.  Evaluates and delegates claims operations as dictated by state law and the SFHP contracts. 

4.  Conducts or supervises periodic audits of delegated claims operations and will be responsible for the documentation, communications, and if necessary the corrective actions required to maintain the delegation of SFHP’s partners as well as the maintenance of SFHP’s own claims processing status as a Medi-Cal organization.

 

Performs all other related duties as directed.

 

Qualifications:



1.  Bachelor’s degree or at least 6 years of related claims/billing experience.

2.  A Coding Certification

3.  A Masters degree would be looked upon favorably.

4.  Two or more years experience in a health care environment, specifically, in managed care.

5.  HMO experience.

6.  Solid and progressive Management/leadership experience.

 

Interested candidates should apply on line at:
https://home.eease.com/recruit/?id=37996

 

Please reference job code DOCMONADP308. If the link does not work (this happens with Craigslist 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

 

About San Francisco Health Plan:

San Francisco Health Plan was created by the City of San Francisco with one purpose: to provide high quality medical care to the largest number of low-income San Francisco residents possible. We currently serve over 50,000 San Franciscans who might not otherwise be able to afford health insurance. Our services are provided through several networks that include primary and specialty care physicians and community-based hospitals and clinics located throughout the City. More information about our organization may be found at www.sfhp.org