Remote Healthcare Claims Resolution Specialist

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

Benefits offered by this job

CalPERS pension

Generous PTO

Tuition Reimbursement

Professional development

Flexible scheduling

Job summary

CalOptima is seeking a Claims Resolution Specialist - Covered California to serve as the first line of contact for providers on claims payment questions and issues. The role emphasizes accuracy in documentation and collaboration within the Claims Production team.

The position supports telework with California residency requirements and may require in-office presence in Orange, CA as needed. A strong customer service mindset and healthcare experience are essential.

Qualifications

• High school diploma or equivalent required, plus 2 years of claims resolution experience.
• 1 year of call center or high-volume customer service experience required.
• 1 year of HMO, Medi-Cal/Medicaid or healthcare/managed care experience preferred.

Responsibilities

• Handle provider questions and research issues related to claims payments and denials.
• Follow up with providers as needed to resolve claims.
• Maintain accurate documentation in claims systems and escalate as necessary.
• Support departmental goals and ensure timely claims processing and service quality.
• Contribute to a culture of customer service, accountability, and collaboration.

Education

High School Diploma or Equivalent

Tools

Microsoft Office

Job description

CalOptima is seeking a Claims Resolution Specialist - Covered California to serve as the first line of contact for providers on claims payment questions and issues. The role emphasizes accuracy in documentation and collaboration within the Claims Production team.

The position supports telework with California residency requirements and may require in-office presence in Orange, CA as needed. A strong customer service mindset and healthcare experience are essential.