Remote Claims Resolution Specialist – Health Plan

CalOptima Health Partnership; Orange (CA); Remote; USD 54,000 - 81,000; Full time

Benefits offered by this job

Comprehensive benefits

PTO program

Tuition Reimbursement

Flexible scheduling

Career development

CalPERS pension

Job summary

CalOptima Health is seeking a Claims Resolution Specialist for the Claims Administration team. This remote role supports Medi-Cal and OneCare claims and ensures adjudication alignment with AB1455 guidelines, while collaborating with providers and stakeholders across California.

The position offers Full Telework with requirement to reside in California, with occasional in-office presence if needed; strong emphasis on accuracy, customer service, and regulatory compliance.

Qualifications

• 2+ years of experience processing online claims in a health care/managed care setting, specifically adjudicating and adjusting claims.
• Experience with Medicare and Medi-Cal billing is preferred.
• High school diploma or equivalent required.

Responsibilities

• Oversee and manage the claims resolution process following AB1455 regulatory guidelines.
• Process Medi-Cal and OneCare claims and identify training opportunities from trend reports.
• Collaborate with claims management and trainers to improve accuracy and efficiency.

Skills

Online claims processing

AB1455 regulatory adherence

Communication skills

Education

High School diploma

Bachelor’s degree in related field

Tools

Microsoft Office

Claims billing systems

Job description

CalOptima Health is seeking a Claims Resolution Specialist for the Claims Administration team. This remote role supports Medi-Cal and OneCare claims and ensures adjudication alignment with AB1455 guidelines, while collaborating with providers and stakeholders across California.

The position offers Full Telework with requirement to reside in California, with occasional in-office presence if needed; strong emphasis on accuracy, customer service, and regulatory compliance.