Coding & Medical Policy Evaluator

California Department of Health Care Services; California (MO); Hybrid; USD 83,000 - 109,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Paid holidays

Vacation/leave

Retirement program

401(k) and 457 plans

HSA/FSA options

Job summary

California Department of Health Care Services in West Sacramento, CA, seeks a Coding & Medical Policy Evaluator to monitor provider claiming patterns and policy implementation. You will analyze data, support policy revisions, and prepare management reports.

Telework is available, with hybrid arrangements and a permanent, full-time classification. Minimum requirements include Nurse Evaluator II, Health Services, and knowledge of Medi-Cal, HCPCS/CPT coding, HIPAA, and MS Office.

Qualifications

• Knowledge of Medi-Cal program policies and regulations.
• Knowledge of HCPCS and CPT coding from state and federal perspectives.
• HIPAA knowledge from state and federal perspectives.
• Ability to research, interpret, and explain Medi-Cal policies for system modifications.
• Ability to develop and maintain effective and cooperative working relationships.
• Ability to work independently, prioritize work, and adapt to changing priorities.
• Ability to provide clear, concise written documentation.
• Proficiency in using Microsoft Office (Outlook, Word, and Excel).

Responsibilities

• Apply medical knowledge to monitor and evaluate provider claiming patterns.
• Monitor implementation and performance of medical policy in the claims processing system.
• Recommend appropriate action based on facts obtained.
• Assist in development and implementation of new or revised Medi-Cal and Public Health Medical Policy.
• Prepare reports for management review and approval.

Skills

Medi-Cal policies

HCPCS & CPT coding

HIPAA knowledge

Policy interpretation

Microsoft Office

Tools

Microsoft Office

Job description

Work Location

Yolo County

Job Description And Duties

Why Join DHCS? The Department of Health Care Services (DHCS) is the backbone of California’s health care safety net. Our success is made possible by the hard work of more than 4,800 DHCS team members and through collaboration with the federal government and other state agencies, counties, and partners for the care of low-income families, children, pregnant women, older adults, and persons with disabilities. This is an exciting opportunity to join our diverse team in the following role.

About this Role

The role of the Coding & Medical Policy Evaluator is to apply medical knowledge to monitor and evaluate provider claiming patterns, monitor implementation and performance of medical policy in the claims processing system, and recommended appropriated action based on the facts obtained. Assist in the development and implementation of new or revised Medi-Cal and Public Health Medical Policy. Prepare reports for management review and approval.

Have questions and/or need assistance? Contact [e-mail] , we are here to help walk you through the state hiring process!

Minimum Requirements

• NURSE EVALUATOR II, HEALTH SERVICES

Position Details

Job Code # JC-531507

Position #(s) 805-440-8144-XXX

Working Title Coding & Medical Policy Evaluator

Classification NURSE EVALUATOR II, HEALTH SERVICES

Salary $7,430.00 - $9,757.00

# of Positions Multiple

Work Location Yolo County

Telework Hybrid

Job Type Permanent, Full Time

Final Filing Date

Final Filing Date: 9/28/2026

Who May Apply

Individuals who are currently in the classification, eligible for lateral transfer, eligible for reinstatement, have list or LEAP eligibility, are in the process of obtaining list eligibility, or have SROA and/or Surplus eligibility (please attach your letter, if available). SROA and Surplus candidates are given priority; therefore, individuals with other eligibility may be considered in the event no SROA or Surplus candidates apply.

Applications will be screened and only the most qualified applicants will be selected to move forward in the selection process. Applicants must meet the Minimum Qualifications stated in the Classification Specification(s).

Desirable Qualifications

• Knowledge of the Medi-Cal Program policies and regulations.
• Knowledge of the Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) coding – from both the State of California and Federal Medicaid perspectives.
• Knowledge of the Health Insurance Portability and Accountability Act (HIPAA) – from both the State of California and Federal perspectives.
• Ability to research, interpret, and explain existing Medi-Cal policies for system modifications.
• Ability to develop and maintain effective and cooperative working relationships.
• Ability to effectively work independently, prioritize work, and adapt to changing priorities.
• Ability to provide clear, concise, and effective written documentation.
• Proficiency in using Microsoft Office (i.e., Outlook, Word, and Excel)

Benefits

• Continuous and ongoing training
• Diversity, Equity, and Inclusion program activities
• Employee Assistance Program (EAP)
• Medical, including health, dental, and vision insurance.
• Paid Holidays and vacation/leave
• Defined retirement program
• Savings Plus Program (401(k), 457)
• Medical/Dependent Care Reimbursement Accounts

Full benefits information can be found on CalHR's California State Civil Service Employee Benefits Summary .

DHCS 2023-2027 Strategic Plan provides more information about our commitment to serving Californians and organizational excellence.

Telework and Salary Information

Standard Telework Language:

Telework: This position is currently eligible for telework. The amount of telework is at the discretion of the Department and is subject to change consistent with DHCS’ Telework Program and Government Code sections 14200 – 14203. Telework is available to California residents, and proof of residency may be required.

Business travel may be required, and reimbursement considers an employee’s designated office and residence subject to regulations and bargaining unit contract provisions. All commute expenses to the reporting location will be the responsibility of the selected candidate.

The DHCS office location for this position is West Sacramento, CA 95605.

Personal Leave Program (PLP) 2025 agreement

Salary: Effective July 1, 2025, the California Department of Human Resources (CalHR) implemented the temporary Personal Leave Program 2025 (PLP 2025). PLP 2025 directs that each employee receive a temporary reduction in pay in exchange for PLP 2025 leave credits. The temporary salary reduction percentage and the number of PLP 2025 leave credits are based on the position’s associated bargaining unit. The salary range(s) included in this job advertisement do not include the temporary salary reduction. Please reach out to the hiring unit contact listed on this job advertisement for details.

Contact Information

Hiring Unit Contact:
RandyGee Woodyard
[phone]
[e-mail]

Please direct requests for Reasonable Accommodations to the interview scheduler at the time the interview is being scheduled. You may direct any additional questions regarding Reasonable Accommodations or Equal Employment Opportunity for this position(s) to the Department's EEO Office.

EEO Contact:
EEO Officer
[phone]
[e-mail]

California Relay Service: 1-800-735-2929 (TTY), 1-800-735-2922 (Voice) TTY is a Telecommunications Device for the Deaf, and is reachable only from phones equipped with a TTY Device.

Equal Opportunity Employer

The State of California is an equal opportunity employer to all, regardless of age, ancestry, color, disability (mental and physical), exercising the right to family care and medical leave, gender, gender expression, gender identity, genetic information, marital status, medical condition, military or veteran status, national origin, political affiliation, race, religious creed, sex (includes pregnancy, childbirth, breastfeeding and related medical conditions), and sexual orientation.

It is an objective of the State of California to achieve a drug-free work place. Any applicant for state employment will be expected to behave in accordance with this objective because the use of illegal drugs is inconsistent with the law of the State, the rules governing Civil Service, and the special trust placed in public servants.