Lead Claims Examiner – Full Telework Eligible

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

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.