Claims Examiner

Claims ExaminerJoin Us in this Amazing OpportunityThe Team You'll JoinWe are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.More About the OpportunityWe are hoping you will join us as a Claims Examiner and help shape the future of healthcare where you'll be an integral part of our Claims Administration team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. 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.The Claims Examiner will be responsible for analyzing and validating claim data elements and claims processing. You will be responsible for adhering to the regulatory and internal processing guidelines in conjunction with CalOptima Health policies and procedures related to claims adjudication. Together, we are building a stronger, more equitable health system.Your Contributions To the Team:85% - Claims SupportPerforms thorough review of pending claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services.Processes non-institutional claim types.Corrects system generated errors manually prior to final claims adjudication.Processes claims based upon CalOptima Health contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and CalOptima Health policies and procedures.Analyzes and validates Medi-Cal pricing; researches, adjusts and adjudicates claims; reviews services for accurate charges and utilizes current billing code sets, including International Classification Diseases (ICD10) codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference.Validates eligibility and other possible health insurance coverage on the claim.Alerts manager or supervisor of more complex issues that arise.Processes claim exception reports as assigned.10% - Administrative SupportParticipates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.5% - Completes other projects and duties as assigned.Do You Have What the Role Requires?High school diploma or equivalent PLUS 1 year 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.You'll Stand Out More If You Possess the Following:Experience processing online claims in a managed care environment.Experience processing Medi-Cal claims.Your Knowledge & Abilities to Bring to this Role:Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.Work independently and exercise sound judgment.Communicate clearly and concisely, both orally and in writing.Work a flexible schedule; available to participate in evening and weekend events.Organize, be analytical, problem-solve and possess project management skills.Work in a fast-paced environment and in an efficient manner.Manage multiple projects and identify opportunities for internal and external collaboration.Motivate and lead multi-program teams and external committees/coalitions.Utilize 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.Your Physical Requirements (With or Without Accommodations):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 poundsWays We Are Here For YouYou'll enjoy competitive compensation for this role.Our current hiring range is: Pay Grade: 301 - $47,840 - $64,584 ($23.00 - $31.0500).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.This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**).CalPERS pension program and additional retirement packages.Additional benefits and perks including:A generous PTO programA quality work life balanceVarious wellness programsTuition ReimbursementProfessional development opportunitiesCareer development opportunitiesFlexible schedulingAnd the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.Our Work Environment:If located at the 500, 505 Building or a remote work location:Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.There are no harmful environmental conditions present for this job.The noise level in this work environment is usually moderate.If located at PACE:Work is typically indoors in a clinical setting serving the frail and elderly.There may be harmful or hazardous environmental conditions present for this job.The noise level in this work environment is usually moderate to loud.If located in the Community:Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.Employee will occasionally work outdoors in varied temperatures.There may be harmful or hazardous environmental conditions present for this job.The noise level in this work environment is usually moderate to loud.Why Join Us?We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.What's Your Next Step?All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is August 31, 2026 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.Our Commitment to YouYour application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal