Business Analyst Sr, Claims, Covered California

CalOptima Health Partnership; Orange (CA); Remote; USD 78,000 - 125,000; Full time

Job summary

CalOptima Health Partnership is seeking aSenior Business Analyst, Claims, Covered California to translate complex business needs into analytical solutions within the Claims Administration team. You will handle adjudication issues, coordinate UAT, and train users on Facets logic while ensuring compliance with DMHC, DHCS, CMS guidance.

This role requires SME capabilities across lines of business and collaboration with providers and stakeholders.

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 qualify.
• 3 years of Medi-Cal managed care or Medicare Advantage experience required.

Responsibilities

• Translate business needs into analytical and reporting solutions for the Claims Administration team.
• Handle complex inquiries and analyze claims adjudication issues.
• Coordinate user acceptance testing and deliver training on Facets logic.
• Provide guidance on DMHC, DHCS and CMS claims regulations and guidance.
• Act as SME for all lines of business and support regulatory alignment across claims processes.

Skills

Claims experience

Regulatory knowledge

Communication skills

Education

Bachelor’s degree in health administration or related field

Tools

Facets system

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 apply today 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 Californiaand help shape the future of healthcare where you’ll be an integral part of our Claims Administrationteam, 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 beFull 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.

The Business Analyst Sr (Claims-Covered California) will support the Claims Administration department by translating comprehensive business needs into actionable analytical and reporting solutions. You will be responsible for handling complex inquiries, analyzing claims adjudication errors, coordinating user acceptance testing and delivering training on new Facets logic. You will support staff on issues related to California Department of Managed Health Care (DMHC), Department of Healthcare Services (DHCS) and Centers for Medicare & Medicaid Services (CMS) claims regulations, reference guides, All Plan Letters (APLs) and other applicable regulatory guidance affecting all lines of business. You will develop and maintain subject matter expertise (SME) for all lines of business, evaluate the impact of process and system configuration changes and provide guidance to the department. Together, we are building a stronger, more equitable health system.

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