Claims Examiner
About the role
Join CalOptima as a Claims Examiner and help shape the future of healthcare. This position is an integral part of our Claims Administration team, focusing on excellence while serving member health with dignity and respect. The role is approved for Full Telework, requiring work within the State of California only. If Partial Telework is approved, you will also need to come into the Main Office in Orange, CA, at least two days per week.
Responsibilities
- Perform thorough review of pending claims for billing errors and/or questionable billing practices, including duplicate billing and unbundling of services.
- Process non-institutional claim types.
- Correct system-generated errors manually prior to final claims adjudication.
- Process claims based on CalOptima Health contractual agreements, pricing agreements, applicable regulatory legislation, claims processing guidelines, and CalOptima Health policies and procedures.
- Analyze and validate Medi-Cal pricing; research, adjust, and adjudicate claims; review services for accurate charges using current billing code sets (ICD-10, CPT) and/or authorization guidelines.
- Validate eligibility and other possible health insurance coverage on claims.
- Alert manager or supervisor of complex issues that arise.
- Process claim exception reports as assigned.
- Participate in a mission-driven culture focused on high-quality performance, customer service, consistency, dignity, and accountability.
- Assist the team in carrying out department responsibilities and collaborate with others to support short- and long-term goals.
- Complete other projects and duties as assigned.
Requirements
- High school diploma or equivalent plus 1 year of related claims processing experience; an equivalent combination of education and experience may also qualify.
- Experience processing online claims in a managed care environment (preferred).
- Experience processing Medi-Cal claims (preferred).
Skills
- Develop rapport and maintain effective working relationships with leadership, staff, and external contacts of diverse backgrounds.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule, including evenings and weekends.
- Organize, analyze, problem-solve, and manage projects effectively.
- Work efficiently in a fast-paced environment.
- Manage multiple projects and identify collaboration opportunities.
- Motivate and lead multi-program teams and external committees/coalitions.
- Utilize computer software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job-specific applications/systems.
Physical Requirements
- Ability to visually read information from computer screens, forms, and other printed materials.
- Ability to speak clearly in conversation and general communication.
- Hearing ability for verbal communication via telephone and face-to-face interactions.
- Manual dexterity for typing, writing, standing, reaching, flexibility, body movement (bending, crouching, walking, kneeling, prolonged sitting).
- Lifting and moving objects, patients, and/or equipment weighing 10 to 25 pounds.
Benefits
- Competitive compensation: Pay Grade 301 - $47,840 - $64,584 ($23.00 - $31.05/hour), based on education, experience, and internal equity.
- Comprehensive benefits package.
- CalPERS pension program and additional retirement packages.
- Generous PTO program.
- Work-life balance initiatives.
- Wellness programs.
- Tuition reimbursement.
- Professional and career development opportunities.
- Flexible scheduling.
Schedule
This position is approved for Full Telework (eligible in California only) or Partial Telework, requiring at least two days per week in the Main Office in Orange, CA. Work schedule may vary, including evenings and weekends as needed.
Work Environment
Work is typically indoors and sedentary, subject to schedule changes and variable work hours. Travel may be required. The noise level is usually moderate. If located at PACE, work may involve a clinical setting serving the frail and elderly, with potential exposure to harmful or hazardous conditions and moderate to loud noise levels. Community-based roles may involve occasional outdoor work in varied temperatures and moderate to loud noise levels.