Business Analyst Sr, Claims - Covered California

About the role

We are seeking a Business Analyst Sr, Claims - Covered California to join our Claims Administration team. This position has been approved to be Full Telework. If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

Responsibilities

• Support the Claims Administration department by translating complex business needs into actionable analytical and reporting solutions.
• Handle complex inquiries, analyze claims adjudication errors, coordinate user acceptance testing and deliver training on new Facets logic.
• Support staff on issues related to California Department of Managed Health Care claims regulations, reference guides and All Plan Letters (APLs) affecting Covered California.
• Serve as the claims subject matter expert (SME) for Covered California product line across all CalOptima Health's departments.
• Evaluate the impact of process and system configuration changes and provide guidance to the department.
• Implement benefits or process changes that impact system configuration due to federal and state notices.
• Support departmental compliance with Covered California and DMHC regulatory requirements, including analyzing guidance, implementing required operational changes and ensuring alignment across claims processes and system configuration.
• Identify training needs and assist in developing desktop procedures and policies for lines of business affected by system or regulatory changes, including updates that directly impact Covered California processes.
• Lead and manage multiple concurrent projects and workflows to ensure timely and accurate completion, including projects that impact Covered California claims, system configuration or regulatory alignment.
• Analyze APLs, MedLearn notices and Medi-Cal monthly bulletins to identify potential impact on the department.
• Provide analytical support and technical expertise to executives, directors and staff by delivering insights on Covered California performance, trends and compliance, while partnering with department leadership and internal teams to identify and implement process improvements that enhance efficiency and compliance in claims operations.

Requirements

• 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.
• 3 years of experience in Medi-Cal managed care or Medicare Advantage required.
• Covered California (Commercial) experience required.
• Direct or indirect experience with health care benefits configuration.
• Perform user acceptance testing of health care benefits.
• Experience participating in cross-functional work groups.

Qualifications

• Knowledge of health care benefits configuration.
• Experience with user acceptance testing of health care benefits.
• Experience with cross-functional work groups.

Skills

• Develops rapport and establishes effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Works independently and exercises sound judgment.
• Communicates clearly and concisely, both orally and in writing.
• Manages multiple projects and identifies opportunities for internal and external collaboration.
• Motivates and leads multi-program teams and external committees/coalitions.
• Utilizes computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Benefits

A comprehensive benefits package including a CalPERS pension program and additional retirement packages. Additional benefits and perks include:

• A generous PTO program
• A quality work-life balance
• Variety of wellness programs
• Tuition reimbursement
• Professional development opportunities
• Career development opportunities
• Flexible scheduling

Pay

The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors. The current hiring range is Pay Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947).

Schedule

This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**).

Physical Requirements

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds.