Remote Lead Claims Examiner

CalOptima Health Partnership; Orange (CA); Remote; USD 56,000 - 84,000; Full time

Benefits offered by this job

Full Telework

Comprehensive benefits

CalPERS pension

Job summary

CalOptima Health Partnership seeks a Claims Examiner - Lead to provide advanced technical expertise and workflow oversight within the CLA - Claims Production team. This role supports claim adjudication, benefit interpretation and regulatory compliance while collaborating with providers and stakeholders.

The position offers Full Telework with optional in-office presence in Orange, CA. You will mentor examiners, monitor productivity, and drive quality, leveraging Facets and Jiva among other

Qualifications

• High school diploma or equivalent plus 3 years of progressive medical claims processing experience in a managed care environment.
• Experience in Facets or related health care claims platforms required.

Responsibilities

• Lead functions: provide real-time guidance, delegate work and support staff development.
• Claims support: monitor queues, analyze dashboards, improve accuracy and cycle time.
• Complete other projects as assigned and contribute to regulatory readiness.

Skills

Leadership

Claims processing

Regulatory compliance

Systems navigation

Education

High school diploma

3+ years claims processing

Bachelor’s degree (nice-to-have)

Tools

Facets

Jiva

Job description

CalOptima Health Partnership seeks a Claims Examiner - Lead to provide advanced technical expertise and workflow oversight within the CLA - Claims Production team. This role supports claim adjudication, benefit interpretation and regulatory compliance while collaborating with providers and stakeholders.

The position offers Full Telework with optional in-office presence in Orange, CA. You will mentor examiners, monitor productivity, and drive quality, leveraging Facets and Jiva among other