Senior Claims Examiner — Remote Telework Eligible

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

Benefits offered by this job

Generous PTO

Flexible scheduling

Tuition Reimbursement

Wellness programs

Career development opportunities

Job summary

CalOptima is seeking a Sr Claims Examiner to analyze and adjudicate complex claims within a primarily remote role. You will ensure compliance with regulatory and internal guidelines while supporting the Claims Administration team in delivering accurate and timely reimbursements.

The position requires a high school diploma or equivalent plus 2 years of related claims processing experience, with preferred familiarity of Medi-Cal and Medicare claims.

Qualifications

• High school diploma or equivalent required with 2+ years of related claims processing experience.
• Experience with processing Medi-Cal and/or Medicare claims is preferred.
• Ability to analyze complex claims and justify adjudication decisions.

Responsibilities

• Analyze and validate claims elements and processing in accordance with regulations and internal policies.
• Adjudicate complex claims requiring additional research or problem-solving.
• Process professional and institutional claim types and review for billing errors.
• Resolve claim exceptions and correct system-generated errors prior to final adjudication.
• Work with CalOptima Health policies to ensure accurate pricing and data integrity.
• Complete other assigned projects and duties as needed.

Skills

Communication

Analytical thinking

Problem solving

Time management

Education

High school diploma or equivalent

Tools

Microsoft Office

Job description

CalOptima is seeking a Sr Claims Examiner to analyze and adjudicate complex claims within a primarily remote role. You will ensure compliance with regulatory and internal guidelines while supporting the Claims Administration team in delivering accurate and timely reimbursements.

The position requires a high school diploma or equivalent plus 2 years of related claims processing experience, with preferred familiarity of Medi-Cal and Medicare claims.