Senior Claims Analyst - Remote (California)

CalOptima Health Partnership; Orange (CA); Remote; USD 78,000 - 125,000; Full time

Job summary

CalOptima Health Partnership is seeking aSenior Business Analyst, Claims, Covered California to translate complex business needs into analytical solutions within the Claims Administration team. You will handle adjudication issues, coordinate UAT, and train users on Facets logic while ensuring compliance with DMHC, DHCS, CMS guidance.

This role requires SME capabilities across lines of business and collaboration with providers and stakeholders.

Qualifications

• Bachelor’s degree in business administration, health care administration, health services or related field PLUS 3 years of experience in claims, managed care benefits and operational protocol in the health care industry required; an equivalent combination of education and experience may qualify.
• 3 years of Medi-Cal managed care or Medicare Advantage experience required.

Responsibilities

• Translate business needs into analytical and reporting solutions for the Claims Administration team.
• Handle complex inquiries and analyze claims adjudication issues.
• Coordinate user acceptance testing and deliver training on Facets logic.
• Provide guidance on DMHC, DHCS and CMS claims regulations and guidance.
• Act as SME for all lines of business and support regulatory alignment across claims processes.

Skills

Claims experience

Regulatory knowledge

Communication skills

Education

Bachelor’s degree in health administration or related field

Tools

Facets system

Microsoft Office

Job description

CalOptima Health Partnership is seeking aSenior Business Analyst, Claims, Covered California to translate complex business needs into analytical solutions within the Claims Administration team. You will handle adjudication issues, coordinate UAT, and train users on Facets logic while ensuring compliance with DMHC, DHCS, CMS guidance.

This role requires SME capabilities across lines of business and collaboration with providers and stakeholders.