Job summary
Job post source
This job is directly from CalOptima
Job overview
The Claims Examiner at CalOptima is responsible for analyzing and validating claim data and processing claims to ensure compliance with regulatory and internal guidelines, impacting the accuracy and efficiency of claims adjudication.
Responsibilities and impact
The Claims Examiner reviews pending claims for errors, processes non-institutional claims, corrects system errors, validates pricing and eligibility, supports the team in department goals, and completes assigned projects.
Compensation and benefits
The position offers a salary range of $47,840 to $64,584 annually, full telework eligibility in California, and a comprehensive benefits package including CalPERS retirement, medical/vision/dental insurance, paid time off, flexible scheduling, telework options, and wellness programs.
Experience and skills
Requires a high school diploma or equivalent plus 1 year of related claims processing experience; preferred experience includes processing online claims in managed care and Medi-Cal claims; skills include communication, judgment, analytical abilities, and proficiency with Microsoft Office and job-specific software.
Work environment and culture
CalOptima promotes a mission-driven, inclusive culture focused on high-quality performance, customer service, diversity, and employee belonging within a collaborative environment.
Company information
CalOptima Health is the largest health plan in Orange County, serving one in four residents, known for its commitment to excellence, dignity, and respect, and recognized as one of Orange County's best places to work.
Job location and travel
The role is fully telework eligible within California, with work typically indoors and sedentary, subject to schedule changes and occasional travel.
Application process
Applications are accepted continuously with a first review deadline of July 11, 2025, 9:00 PM PST; the selection process may include skills assessment, phone screen, interview, and background check; applicants should apply early and monitor email for communication.
Unique job features
The job offers full telework flexibility, participation in a diverse and inclusive workplace, and involvement in a mission-driven organization focused on community health.
Company overview
CalOptima is a public agency in Orange County, California, providing health insurance programs for low-income residents, including Medi-Cal, OneCare, and PACE. Established in 1993, it serves over 800,000 members by partnering with local healthcare providers to offer comprehensive medical, dental, and mental health services. CalOptima generates revenue through government funding and reimbursements for managing these health programs. The organization is known for its commitment to improving healthcare access and quality for vulnerable populations in the region.
How to land this job
Position your resume to highlight your experience with claims processing, emphasizing your ability to analyze and validate claim data and adhere to regulatory and internal guidelines as outlined by CalOptima Health policies.
Focus on showcasing your knowledge of Medi-Cal claims, billing codes such as ICD10 and CPT, and your skill in identifying billing errors, duplicate billing, or unbundling practices to align with the job's key responsibilities.
Apply through multiple platforms including CalOptima's official careers page and LinkedIn to maximize your chances of being noticed and considered for the Claims Examiner role.
Connect on LinkedIn with current employees in CalOptima's Claims Administration department or related divisions, using ice breakers like asking about their experience working remotely or in claims adjudication, or expressing interest in CalOptima's mission of serving the community with dignity and respect.
Optimize your resume for ATS by incorporating keywords directly from the job description such as 'claims adjudication,' 'Medi-Cal pricing,' 'billing errors,' 'ICD10,' 'CPT codes,' and 'claims processing guidelines' to ensure your resume passes initial automated screenings.
Use Jennie Johnson's Power Apply feature to automate your applications across multiple sites, tailor your resume with relevant keywords, and identify LinkedIn connections to network with, allowing you to focus your time on preparing for interviews and further research.
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