Claims Resolution Specialist

Claims Resolution Specialist CalOptima Join Us in this Amazing Opportunity We 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. About the Role As a Claims Resolution Specialist, you will be the first line of contact for CalOptima Health providers, assisting them with questions related to the payment of claims and resolution of claims payment issues. Training will be held in the office for the first 2 weeks, Monday – Friday from 8:00am – 4:30pm. The position is approved for Full Telework within California; partial telework requires in‑office presence at least two days per week. Your Contributions To the Team 80% - Claims Support: Respond to provider questions, research issues regarding claims payments, denials, contracts, agreements, payment methodologies, regulatory legislation, and company policies. Follow up with providers and route escalated calls to appropriate departments. 15% - Administrative Support: Participate in a culture of high-quality performance with a member focus on customer service, consistency, dignity, and accountability. Assist the team with department responsibilities, collaborate on short-and-long term goals, ensure accurate and timely documentation in Facets. 5% - Other: Complete other duties or projects as assigned. Qualifications High school diploma or equivalent plus 2 years of experience in claims resolution (or an equivalent combination of education and experience). 1 year of call center experience with high call volumes or customer service experience. 1 year of HMO, Medi‑Cal/Medicaid, and healthcare/managed care experience. Desired Abilities Develop rapport and maintain effective working relationships with leadership, staff, and external contacts at all levels and diverse backgrounds. Work independently and exercise sound judgment. Communicate clearly and concisely, orally and in writing. Work a flexible schedule, including evenings and weekends as needed. Organize, analyze, problem-solve, and manage multiple projects. Motivate and lead multi-program teams and external committees/coalitions. Utilize Microsoft Office (Word, Outlook, Excel, PowerPoint) and job-specific applications/systems. Physical Requirements Ability to visually read information from screens, forms, and printed materials. Clear verbal communication and hearing ability for telephone and face-to-face interactions. Manual dexterity for typing, writing, standing, reaching, flexibility, and moving. Ability to lift and move objects up to 25 pounds. Benefits Competitive compensation within Pay Grade 304 ($53,813 – $80,720). CalPERS pension program and additional retirement packages. Generous paid time off, flexible scheduling, and quality work-life balance. Various wellness programs and tuition reimbursement. Professional and career development opportunities. Impactful work improving healthcare access for thousands of individuals and families. Work Environment Work is typically indoor, sedentary, and may involve variable hours and travel. No harmful environmental conditions are present. Noise levels are moderate. (Details vary by location.) EEO Statement CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health prohibits unlawful discrimination against any employee or applicant based on race, religion, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, gender identity, etc. Qualified individuals with disabilities may request reasonable accommodations upon application. #J-18808-Ljbffr