Senior Claims Examiner - Fully Remote Healthcare Claims

CalOptima Health Partnership; Orange (CA); Remote; USD 52,000 - 72,000; Full time

Benefits offered by this job

Full Telework

Comprehensive benefits

CalPERS pension

Generous PTO

Wellness programs

Tuition Reimbursement

Professional development

Flexible scheduling

Job summary

CalOptima Health is seeking a Sr Claims Examiner to support the Claims Administration team. The role emphasizes analyzing and validating complex claims, adhering to regulations, and collaborating across providers and stakeholders in a telework-enabled environment.

The position requires a high school diploma with 2 years of claims processing experience, and offers full telework within California along with comprehensive benefits and ongoing career development opportunities.

Qualifications

• High school diploma or equivalent PLUS 2 years of related claims processing experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
• Experience processing online claims in a managed care environment.
• Experience processing Medi-Cal and/or Medicare claims.

Responsibilities

• Analyze and validate claims elements and claims processing.
• Adhere to regulatory and internal guidelines in conjunction with CalOptima Health’s policies and procedures related to claims adjudication.
• Adjudicate more complex claims which require additional research or problem-solving.
• Process professional and institutional claim types.
• Perform thorough review of pending claims for billing errors and questionable billing practices, including duplicate billing and unbundling of services.
• Correct system-generated errors manually prior to final claims adjudication.
• Process claims based upon CalOptima Health’s contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and CalOptima Health’s policies and procedures.
• Analyze and validate Medi-Cal and/or Medicare claims pricing; research, adjust and adjudicate claims; review services for accurate charges, utilizing billing code sets and/or authorization guidelines as a reference.
• Process claim exception reports as assigned.

Skills

Claims processing

Research & problem solving

Analytical thinking

Communication

Team collaboration

Education

High school diploma or equivalent

Job description

CalOptima Health is seeking a Sr Claims Examiner to support the Claims Administration team. The role emphasizes analyzing and validating complex claims, adhering to regulations, and collaborating across providers and stakeholders in a telework-enabled environment.

The position requires a high school diploma with 2 years of claims processing experience, and offers full telework within California along with comprehensive benefits and ongoing career development opportunities.