Remote Claims Resolution Specialist – Healthcare

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

Benefits offered by this job

Comprehensive benefits

CalPERS pension

Generous PTO

Flexible scheduling

Tuition reimbursement

Professional development

Career development

Wellness programs

Job summary

CalOptima Health is seeking a Claims Resolution Specialist for Covered California to oversee and streamline the claims resolution process. This role supports Medi-Cal and OneCare claims, adheres to AB1455 regulatory guidelines, and collaborates with claims management to deliver efficient adjudication.

The position allows full telework with California-only travel if needed. The team emphasizes a member-centric approach, collaboration with providers and stakeholders, and maintaining high-quality

Qualifications

• High School diploma or equivalent required.
• 2 years of experience processing online claims in a health care/managed care setting.
• 1 year of experience in both Medicare and Medi-Cal billing required.

Responsibilities

• Adjudicate and adjust claims accurately and timely according to guidelines.
• Follow AB1455 regulatory guidelines in processing claims.
• Process Medi-Cal and OneCare claims.
• Identify training opportunities from trend reports with claims management and trainers.
• Collaborate with claims management and trainers to improve processes.

Skills

Claims processing

Regulatory compliance

Healthcare billing

Communication skills

Microsoft Office

Education

High School diploma or equivalent

Bachelor’s degree in related field (preferred)

Tools

Claims billing systems

Job description

CalOptima Health is seeking a Claims Resolution Specialist for Covered California to oversee and streamline the claims resolution process. This role supports Medi-Cal and OneCare claims, adheres to AB1455 regulatory guidelines, and collaborates with claims management to deliver efficient adjudication.

The position allows full telework with California-only travel if needed. The team emphasizes a member-centric approach, collaboration with providers and stakeholders, and maintaining high-quality