CalOptima
Overview
Claims Examiner Sr — CalOptima Health. Join a mission‑driven, community‑based organization that serves member health with excellence and dignity. You will analyze and validate claims elements and processing, adhere to regulatory and internal guidelines, and adjudicate more complex claims requiring additional research or problem solving. Together, we strive for an equitable health system through collaboration with providers, community partners, and local stakeholders. Responsibilities
Analyze and validate claims elements and processing for professional and institutional claim types. Adjudicate more complex claims requiring additional research or problem solving. Adhere to regulatory and internal guidelines related to claims adjudication and CalOptima Health policies and procedures. Review pending claims for billing errors and questionable practices, including duplicate billing and unbundling of services; correct system‑generated errors prior to final adjudication. Process claims based on contractual and pricing agreements, applicable regulatory requirements, and internal processing guidelines. Analyze Medi‑Cal and/or Medicare claims pricing; research, adjust, and adjudicate claims; verify services for accurate charges using coding references. Process claim exception reports as assigned. Qualifications
High school diploma or equivalent plus 2 years of related claims processing experience; an equivalent combination of education and experience may qualify. Experience processing online claims in a managed care environment and with Medi‑Cal and/or Medicare claims is preferred. Knowledge & Abilities
Develop rapport and maintain effective working relationships with leadership, staff, and external contacts at all levels. Work independently, exercise sound judgment, and communicate clearly in writing and verbally. Flexible schedule; able to participate in evening and weekend events. Organize, analyze, problem‑solve, and manage multiple projects with internal and external collaboration. Proficient with Microsoft Office and job‑specific applications; produce correspondence, charts, and reports. Physical Requirements
Ability to read information on screens and printed materials; articulate speech clearly; and hear for verbal communication. Manual dexterity for typing and general movements; ability to lift and move objects up to 25 pounds. Work Environment & Benefits
Full telework option (California only) with a comprehensive benefits package and CalPERS pension. Generous PTO, wellness programs, tuition reimbursement, professional and career development opportunities, and flexible scheduling. Work environments vary by location (office, remote, or clinical settings) with typical indoor, sedentary work; some roles may involve travel or varied environmental conditions. What’s the Next Step
Applications are accepted on a continuous basis until qualified applications are received. First review deadline: November 13, 2025 at 9:00 PM (PST). Late applications may not be considered. The recruitment may close without notice after the first review date. A dedicated recruiter will review applications and may include assessments, phone screens, and interviews. Final steps may include reference checks, background checks, and drug screening where applicable. Equal Opportunity
CalOptima Health is an equal opportunity employer. We prohibit unlawful discrimination based on race, religion, color, national origin, disability, genetic information, marital status, sex, gender identity, age, sexual orientation, immigration status, military status, and other protected characteristics. Reasonable accommodations are available for applicants with disabilities upon request. To apply, please visit: https://jobs.caloptima.org/jobs/claims-examiner-sr-505-city-parkway-west-california-united-states-55768582-cbb1-4f0a-9b91-f24bd96b3864
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Claims Examiner Sr — CalOptima Health. Join a mission‑driven, community‑based organization that serves member health with excellence and dignity. You will analyze and validate claims elements and processing, adhere to regulatory and internal guidelines, and adjudicate more complex claims requiring additional research or problem solving. Together, we strive for an equitable health system through collaboration with providers, community partners, and local stakeholders. Responsibilities
Analyze and validate claims elements and processing for professional and institutional claim types. Adjudicate more complex claims requiring additional research or problem solving. Adhere to regulatory and internal guidelines related to claims adjudication and CalOptima Health policies and procedures. Review pending claims for billing errors and questionable practices, including duplicate billing and unbundling of services; correct system‑generated errors prior to final adjudication. Process claims based on contractual and pricing agreements, applicable regulatory requirements, and internal processing guidelines. Analyze Medi‑Cal and/or Medicare claims pricing; research, adjust, and adjudicate claims; verify services for accurate charges using coding references. Process claim exception reports as assigned. Qualifications
High school diploma or equivalent plus 2 years of related claims processing experience; an equivalent combination of education and experience may qualify. Experience processing online claims in a managed care environment and with Medi‑Cal and/or Medicare claims is preferred. Knowledge & Abilities
Develop rapport and maintain effective working relationships with leadership, staff, and external contacts at all levels. Work independently, exercise sound judgment, and communicate clearly in writing and verbally. Flexible schedule; able to participate in evening and weekend events. Organize, analyze, problem‑solve, and manage multiple projects with internal and external collaboration. Proficient with Microsoft Office and job‑specific applications; produce correspondence, charts, and reports. Physical Requirements
Ability to read information on screens and printed materials; articulate speech clearly; and hear for verbal communication. Manual dexterity for typing and general movements; ability to lift and move objects up to 25 pounds. Work Environment & Benefits
Full telework option (California only) with a comprehensive benefits package and CalPERS pension. Generous PTO, wellness programs, tuition reimbursement, professional and career development opportunities, and flexible scheduling. Work environments vary by location (office, remote, or clinical settings) with typical indoor, sedentary work; some roles may involve travel or varied environmental conditions. What’s the Next Step
Applications are accepted on a continuous basis until qualified applications are received. First review deadline: November 13, 2025 at 9:00 PM (PST). Late applications may not be considered. The recruitment may close without notice after the first review date. A dedicated recruiter will review applications and may include assessments, phone screens, and interviews. Final steps may include reference checks, background checks, and drug screening where applicable. Equal Opportunity
CalOptima Health is an equal opportunity employer. We prohibit unlawful discrimination based on race, religion, color, national origin, disability, genetic information, marital status, sex, gender identity, age, sexual orientation, immigration status, military status, and other protected characteristics. Reasonable accommodations are available for applicants with disabilities upon request. To apply, please visit: https://jobs.caloptima.org/jobs/claims-examiner-sr-505-city-parkway-west-california-united-states-55768582-cbb1-4f0a-9b91-f24bd96b3864
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