Claims Examiner Sr

CalOptima; Orange (CA); Remote; USD 52,000 - 72,000; Full time

Benefits offered by this job

Generous PTO

Flexible scheduling

Tuition Reimbursement

Wellness programs

Career development opportunities

Job summary

CalOptima is seeking a Sr Claims Examiner to analyze and adjudicate complex claims within a primarily remote role. You will ensure compliance with regulatory and internal guidelines while supporting the Claims Administration team in delivering accurate and timely reimbursements.

The position requires a high school diploma or equivalent plus 2 years of related claims processing experience, with preferred familiarity of Medi-Cal and Medicare claims.

Qualifications

• High school diploma or equivalent required with 2+ years of related claims processing experience.
• Experience with processing Medi-Cal and/or Medicare claims is preferred.
• Ability to analyze complex claims and justify adjudication decisions.

Responsibilities

• Analyze and validate claims elements and processing in accordance with regulations and internal policies.
• Adjudicate complex claims requiring additional research or problem-solving.
• Process professional and institutional claim types and review for billing errors.
• Resolve claim exceptions and correct system-generated errors prior to final adjudication.
• Work with CalOptima Health policies to ensure accurate pricing and data integrity.
• Complete other assigned projects and duties as needed.

Skills

Communication

Analytical thinking

Problem solving

Time management

Education

High school diploma or equivalent

Tools

Microsoft Office

Job description

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.

Claims Examiner Sr

CalOptima

Join Us in this Amazing Opportunity

We are hoping you will join us as a Claims Examiner Sr 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.

More About The Opportunity

• 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 Sr will be responsible for analyzing and validating claims elements and claims processing. You will adhere to regulatory and internal guidelines in conjunction with CalOptima Health's policies and procedures related to claims adjudication. You will be responsible for adjudicating more complex claims which require additional research or problem-solving. Together, we are building a stronger, more equitable health system.

Your Contributions To The Team

• 95% - Claims 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.
  • Conducts research and problem solves the more complex claims.
  • Processes professional and institutional claim types.
  • Performs thorough review of pending claims for billing errors and questionable billing practices, including duplicate billing and unbundling of services.
  • Corrects system-generated errors manually prior to final claims adjudication.
  • Processes claims based upon CalOptima Health's contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and CalOptima Health's policies and procedures.
  • Analyzes and validates Medi-Cal and/or Medicare claims pricing; researches, adjusts and adjudicates claims; reviews services for accurate charges, utilizing billing code sets and/or authorization guidelines as a reference.
  • Processes claim exception reports as assigned.
• 5% - Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• High school diploma or equivalent PLUS 2 years of related claims processing experience 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.

You'll Stand Out More If You Possess The Following

• Experience processing online claims in a managed care environment.
• Experience processing Medi-Cal and/or Medicare claims.

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: 303 - $51,744 - $72,441 ($24.88 - $34.8274).
  • 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

• 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

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.

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