Business Analyst Sr, Claims, Covered California

CalOptima Health Partnership; Florida; Remote; USD 78,000 - 125,000; Full time

Benefits offered by this job

Full Telework

Competitive compensation

Comprehensive benefits

Job summary

CalOptima Health is seeking a Senior Business Analyst, Sr, Claims, Covered California, to join our Claims Administration team. The role supports and advances regulatory compliance, system configuration, and analytical insights to optimize Covered California processes.

The position offers Full Telework with the requirement to operate within California. You will lead complex analyses, coordinate with cross-functional teams, and ensure timely, accurate results across multiple projects.

Qualifications

• Bachelor's degree in business administration, health care administration, health services or related field PLUS 3 years of experience in claims, managed care benefits and operational protocol in the health care industry required; an equivalent combination of education and experience may also qualify.
• 3 years of experience in Medi-Cal managed care or Medicare Advantage required.

Responsibilities

• Provides business support to the Claims Administration team and handles multiple concurrent projects.
• Leads analyses of regulatory notices and system configuration impacts on Covered California processes.
• Trains staff on system enhancements and changes driven by Covered California requirements.
• Supports executives with analytics on performance, trends and compliance.

Skills

Claims experience

Regulatory awareness

Analytical thinking

Communication skills

Education

Bachelor's degree in business administration/healthcare

Tools

Microsoft Office

Job description

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a Business Analyst Sr, Claims, Covered California and help shape the future of healthcare where you'll be an integral part of our Claims Administration team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework.

• If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum

Your Contributions To the Team:

• 90% - Business Support
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Provides guidance and supports department staff with escalated issues and inquiries related to Covered California benefits, regulations and claims processing requirements.
• Leads and manages multiple concurrent projects and workflows to ensure timely and accurate completion, including projects that impact Covered California claims, system configuration or regulatory alignment.
• Analyzes APLs, MedLearn notices and Medi-Cal monthly bulletins to identify potential impact on the department.
• Implements benefits or process changes that impact system configuration due to federal and state notices.
• Supports departmental compliance with applicable state and federal regulatory requirements, including analyzing guidance, implementing required operational changes and ensuring alignment across claims processes and system configuration.
• Identifies training needs and assists in developing desktop procedures and policies for lines of business affected by system or regulatory changes, including updates that directly impact Covered California processes.
• Participates in cross departmental workgroups and discussions related to program implementation, including initiatives tied to Covered California and system or regulatory changes that affect claims.
• Serves as the department's SME for all lines of business, leading advanced claims analyses, case research and documentation, while conducting system testing to ensure regulatory, coding, contract and configuration updates perform as intended and are accurately documented.
• Trains staff regarding system enhancements or changes, including updates driven by Covered California requirements, deficiencies identified from claims look-back analysis and User Acceptance Testing (UAT) findings.
• Provides analytical support and technical expertise to executives, directors and staff by delivering insights on Covered California performance, trends and compliance, while partnering with department leadership and internal teams to identify and implement process improvements that enhance efficiency and compliance in claims operations.
• 10% - Other
• Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• Bachelor's degree in business administration, health care administration, health services or related field PLUS 3 years of experience in claims, managed care benefits and operational protocol in the health care industry required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
• 3 years of experience in Medi-Cal managed care or Medicare Advantage required.

You’ll Stand Out More If You Possess the Following:

• Direct or indirect experience with health care benefits configuration.
• Perform user acceptance testing of health care benefits.
• Experience participating in cross-functional work groups.
• Experience with Covered California (Commercial) requirements.

What the Regulatory Agencies Need You to Possess?

• N/A

Your Knowledge & Abilities to Bring to this Role:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Ways We Are Here For You

• You’ll enjoy competitive compensation for this role.
• Our current hiring range is: Pay Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947).
• The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.
• This position is approved for Full Telework (If the position is Telework, it is eligible in California only)
• A comprehensive benefits package
• CalPERS pension program and additional retirement packages.
• Additional benefits and perks including:
• A generous PTO program
• A quality work life balance
• Various wellness programs
• Tuition Reimbursement
• Professional development opportunities
• Career development opportunities
• Flexible scheduling
• And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

Why Join Us?

We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.

Our Commitment to You

If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions).

We will make sure to keep you updated through each step of the process on your candidate portal.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at [phone] if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.