Claims Resolution Specialist, Covered

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.

We are hoping you will join us as a Claims Resolution Specialist, Covered California 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 Resolution Specialist (Claims) will be responsible for overseeing and managing the claims resolution process. You will follow regulatory and internal guidelines in conjunction with Cal Optima Health’s policies and procedures that apply to claims adjudication and adjustment of claims. You will work closely with claims management and trainers to identify training opportunities from trend reports. You will also process Medi-Cal and One Care claims.
Together, we are building a stronger, more equitable health system.

• 95% - Claims Support
  • Participates 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.
  • Responsible for accurate and timely adjudication of claims according to AB1455 regulatory guidelines.
  • Processes claims based upon contractual and/or Cal Optima Health’s agreements involving the use of established payment methodologies, division of financial responsibility, applicable regulatory legislation, claim processing guidelines and company policies and procedures.
  • Informs the supervisor or manager of issues impacting production and quality (i.e., incorrect database configurations, incorrect claim payments, etc.).
  • Analyzes, processes, researches and adjusts all provider reconsideration requests and correspondence.
• 5% - Completes other duties or projects as assigned.

• High School diploma or equivalent required.
• 2 years of experience processing on-line claims in a health care/managed care setting specifically in adjudicating and adjusting claims required.
• 1 year of experience in both Medicare and Medi-Cal billing 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.

• Bachelor’s degree in business administration, health care management or related field.
• Experience in claims billing systems.

• N/A

• Develop rapport and establish and maintain effective working relationships with Cal Optima 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…