Job Description
Department(s): Claims Administration
Reports to: Manager, Claims (Operational Support)
FLSA status: Non-Exempt
Salary Grade: F - $24.52 - $35.42 ($51,000 - $73,700)

About CalOptima Health

CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!

About the Position

The Claims Resolution Specialist, Provider Dispute Resolution (PDR) will be responsible for overseeing and managing the PDR process. The incumbent will be responsible for following regulatory and internal guidelines in conjunction with CalOptima Health's policies and procedures that apply to claims adjudication and adjustment of claims when processing provider disputes. The incumbent will work closely with claims management and trainers to identify training opportunities from trend reports. The incumbent will also process Medi-Cal and OneCare claims.

Duties and Responsibilities:

• 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 PDR claims according to AB1455 regulatory guidelines.
• Processes resolutions based upon contractual and/or CalOptima 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 supervisor or manager of issues impacting production and quality (i.e., incorrect database configurations, non-compliant PDR, etc.).
• Responds to incoming calls from providers of service relating to PDR.
• Analyzes, processes, researches and adjusts all provider reconsideration requests and correspondence.
• Completes other projects and duties as assigned.

Experience & Education:

• 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 is also qualifying.

Preferred Qualifications:

• Bachelor's degree in Business Administration, Health Care Management or related field.
• Previous experience in claims billing systems.

About our Benefits & Wellness options:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.



Job Location: Orange, California
Position Type:

To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4103

jeid-44e83d73ad04554d814dc41dafe2d971