Claims Examiner Sr

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 Sr 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 Sr will be responsible for analyzing and validating claims elements and claims processing. You will adhere to regulatory and internal guidelines in conjunction with Cal Optima Health’s policies and procedures related to claims adjudication. You will be responsible for adjudicating more complex claims which require additional research or problem-solving. 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.
  • Conducts research and problem solves the more complex claims.
  • Processes professional and institutional claim types.
  • Performs thorough review of pending claims for billing errors and questionable billing practices, including duplicate billing and unbundling of services.
  • Corrects system-generated errors manually prior to final claims adjudication.
  • Processes claims based upon Cal Optima Health’s contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and Cal Optima Health’s policies and procedures.
  • Analyzes and validates Medi-Cal and/or Medicare claims pricing; researches, adjusts and adjudicates claims; reviews services for accurate charges, utilizing billing code sets and/or authorization guidelines as a reference.
  • Processes claim exception reports as assigned.
• 5% - Completes other projects and duties as assigned.

• High school diploma or equivalent PLUS 2 years 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.

• Experience processing online claims in a managed care environment.
• Experience processing Medi-Cal and/or Medicare claims.

• 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…