Claims Examiner - Lead 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 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 Examiner - Lead 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 Examiner – Lead will provide advanced technical expertise, workflow oversight and operational support within the Claims Administration department. You will serve as a subject matter expert in claim adjudication, systems navigation, benefit interpretation and regulatory compliance. You will partner closely with the supervisor to guide daily operations, delegate work, support staff development, monitor productivity and quality metrics and ensure accurate and timely processing across all lines of business.

You will support team decision making to maintain departmental service levels and regulatory standards. Together, we are building a stronger, more equitable health system.

• 50% - Lead Functions
  • 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.
  • Provides real time technical guidance to Claims Examiners of all levels, assisting with complex claims, escalations, pricing exceptions, configuration issues and system navigation.
  • Serves as primary resource for complex claim types, adjustments, authorization linkage, benefit application, coordination of benefit and specialized provider inquiries.
  • Leads or contributes to system testing, configuration validation and implementation of updates in Facets, Jiva or other internal platforms.
  • Supports supervisor with operational planning, workflow improvements and identifying opportunities for automation or error reduction.
  • Supports training activities by assisting new Claims Examiners and collaborating with the Training Administrator, Business Analysts and Quality Improvement teams.
  • Provides clear communication to Claims Examiners and leadership regarding new procedures, system changes, quality findings and department initiatives.
  • Participates in department meetings, work groups and cross functional discussions.
• 45% - Claims Support
  • Monitors team queues and daily inventory reports, redistributing work as needed based on staffing levels, aging claims, processing trends and department priorities.
  • Reviews performance dashboards and trending reports, escalates risks and recommends process changes to improve accuracy, compliance and cycle…