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Home » Job Board » CA »

Claims Examiner - Lead

Orange, CA



Job Description:

Claims Examiner - Lead


Job Description


Department(s): Claims Administration

Reports to: Supervisor, Claims

FLSA status: Non-Exempt

Salary Grade: F - $51,000 - $67,000


Job Summary


This role provides processing guidance and direction to trainees and Claims Examiners when handling complex or escalated claims and special projects. The Claims Examiner - Lead monitors daily inventory reports, staff work queues in Facets and provides subject matter support to the Supervisor or Manager. In the absence of the Supervisor, the Lead oversees the claims processing activities of Examiners, at all levels, and support staff.


Position Responsibilities:


• Provides technical and/or process direction to Claims Examiners at all levels, ensures claims are completed and adjusted within the department's performance guidelines, oversees that team achieves results and serves as project and/or system testing support for the department.

• Monitors staff's workload in Facets queues, reviews claim inventory discrepancies and assigns work around absences and other scheduling conflicts.

• Identifies, advises, and supports management team of claims processing trends, discrepancies, problems, and issues, and recommends courses of action.

• Informs management of new procedures and ideas for continuous process improvement/implementation, training, and quality audits, and coordinates with department Trainer, Business System Analyst, and Process Improvement Coordinator.

• Compiles, reviews, and analyzes management reports and takes appropriate action.

• Performs quality review or audit on new hires and any examiners placed on quality-focused audit requirements.

• Acts as the subject matter expert for complex claim types, adjustments, training, and provider claims inquiries, procedural or special requests adhering to claims processing policies and procedures.

• Informs Supervisor/Manager of department inventory status (high volume, aging claims, etc.)

• Represents Supervisor/Manager at meetings in their absence as appropriate.

• Other projects and duties as assigned.


Possesses the Ability To:


• Establish and maintain interpersonal relationships internally/externally and utilize skills through effective conflict resolution.

• Organize, prioritize work activities, problem-solve, analyze, and interpret data.

• Interact with teams, encourage, negotiate, and influence others using a positive approach.

• Troubleshoot claims processing technical problem areas.

• Remain objective when dealing with difficult topics and/or giving feedback to peers.

• Create reports and calculations.

• Train specific CalOptima Direct line of business in the absence of a trainer and supervisor.

• Communicate clearly and concisely verbally and in writing, including presentations and when communicating with individuals of diverse backgrounds.

• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.


Experience & Education:


• High school diploma or equivalent work experience is required.

• 3+ years of related claims processing experience required.


Preferred Qualifications:


• Associate degree or Bachelor's degree in Health Care Management or related field preferred.

• Team leadership role in a managed care environment preferred.


Knowledge of:


• Strong knowledge in medical claims administration/processing, including medical terminology, revenue codes, International Classification Disease (ICD)-10 and Healthcare Common Procedure Code System (HCPCS) codes.

• Claims management processes, industry pricing methodologies, such as Resource Based Relative Value Scale, Medicare/Medi-Cal Fee Schedules, etc.

• Medi-Cal and/or Medicare Claims regulatory guidelines.

• Claims Benefit interpretation and administration.

• Department performance and inventory trending reports, their purpose and how to interpret them.


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. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.


Job Location: Orange, California


Position Type:


To apply, visit


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07/06/2021 08/05/2021



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