Claims Examiner - Lead Covered California

CalOptima; Orange (CA); Remote; USD 56,000 - 84,000; Full time

Benefits offered by this job

Full Telework

Comprehensive benefits package

CalPERS pension program

Generous PTO program

Career development opportunities

Job summary

CalOptima in Orange, CA seeks a Lead Claims Examiner to oversee complex claim adjudication, ensure regulatory compliance, and guide the Claims Administration team across all lines of business.

The role partners with supervisors to optimize workflow, monitor quality metrics, and support staff development, with strong emphasis on accuracy and collaboration with providers and stakeholders.

Qualifications

• High school diploma or equivalent plus 3 years of progressively responsible medical claims processing experience in a managed care or health plan environment required.
• Experience in Facets or related healthcare claims platforms required.

Responsibilities

• Leads the Claims Administration team, providing advanced technical guidance and overseeing workflow and performance.
• Supports complex claims, pricing exceptions, system navigation and regulatory compliance across all lines of business.
• Monitors queues, analyzes dashboards, and suggests process improvements to improve accuracy and cycle time.
• Completes other projects and duties as assigned to support departmental objectives.

Skills

Claims processing

Regulatory compliance

Team leadership

Healthcare industry knowledge

Tools

Facets system

Job description

Claims Examiner - Lead Covered California

CalOptima

Join Us in this Amazing Opportunity

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.

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 Claims Examiner - Lead 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.

The Claims Examiner - Lead will provide advanced technical expertise, workflow oversight and operational support within the Claims Administration department. You will serve as a subject matter expert in claim adjudication, systems navigation, benefit interpretation and regulatory compliance. You will partner closely with the supervisor to guide daily operations, delegate work, support staff development, monitor productivity and quality metrics and ensure accurate and timely processing across all lines of business. You will support team decision making to maintain departmental service levels and regulatory standards.Together, we are building a stronger, more equitable health system.

Your Contributions To The Team

• 50% - Lead Functions
  • 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 real time technical guidance to Claims Examiners of all levels, assisting with complex claims, escalations, pricing exceptions, configuration issues and system navigation.
  • Serves as primary resource for complex claim types, adjustments, authorization linkage, benefit application, coordination of benefit and specialized provider inquiries.
  • Leads or contributes to system testing, configuration validation and implementation of updates in Facets, Jiva or other internal platforms.
  • Supports supervisor with operational planning, workflow improvements and identifying opportunities for automation or error reduction.
  • Supports training activities by assisting new Claims Examiners and collaborating with the Training Administrator, Business Analysts and Quality Improvement teams.
  • Provides clear communication to Claims Examiners and leadership regarding new procedures, system changes, quality findings and department initiatives.
  • Participates in department meetings, workgroups and cross functional discussions.
• 45% - Claims Support
  • Monitors team queues and daily inventory reports, redistributing work as needed based on staffing levels, aging claims, processing trends and department priorities.
  • Reviews performance dashboards and trending reports, escalates risks and recommends process changes to improve accuracy, compliance and cycle time.
  • Maintains awareness of state and federal regulatory requirements, including Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS), Medi Cal, Medicare and internal CalOptima Health policies.
  • Responds to provider inquiries, internal escalations and cross department issues requiring advanced claims expertise.
  • Assists with departmental projects, audits or regulatory readiness activities.
• 5% - Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• High school diploma or equivalent PLUS 3 years of progressively responsible medical claims processing experience in a managed care or health plan environment 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.
• Experience in Facets or related health care claims platforms required.

You’ll Stand Out More If You Possess The Following

• Bachelor's degree in healthcare administration, business or a related field.
• Experience in a lead or mentoring role within a claims or health plan setting.

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: 305 - $55,966 - $83,949 ($26.91 - $40.3601).
• 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.

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.