Senior Claims Examiner – Remote (California)

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

Benefits offered by this job

Full Telework

Comprehensive benefits package

CalPERS pension program

Generous PTO

Flexible scheduling

Tuition Reimbursement

Professional development opportunities

Career development opportunities

Job summary

CalOptima Health in California is seeking a Sr. Claims Examiner, Covered California, to analyze and adjudicate complex medical and institutional claims in a telework-enabled role.

You will ensure compliance with regulatory and internal guidelines while collaborating with providers and care teams. The position requires a high school diploma and 2 years of claims processing experience, plus experience with Medi-Cal/Medicare.

Qualifications

• High school diploma or equivalent required; 2 years of related claims processing experience preferred.
• Experience processing online claims in a managed care environment is a plus.
• Experience processing Medi-Cal and/or Medicare claims preferred.

Responsibilities

• Analyze and validate more complex claims and perform research to resolve issues.
• Process professional and institutional claim types.
• Review pending claims for billing errors and questionable billing practices.
• Correct system-generated errors prior to final adjudication.
• Adjudicate claims in accordance with contractual and regulatory guidelines.

Skills

Analytical thinking

Attention to detail

Communication skills

Education

High school diploma or equivalent

Tools

Microsoft Office

Job description

CalOptima Health in California is seeking a Sr. Claims Examiner, Covered California, to analyze and adjudicate complex medical and institutional claims in a telework-enabled role.

You will ensure compliance with regulatory and internal guidelines while collaborating with providers and care teams. The position requires a high school diploma and 2 years of claims processing experience, plus experience with Medi-Cal/Medicare.