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Business Analyst (Claims) CalOptima CalOptima Health is seeking a highly motivated Business Analyst (Claims) to join our team. Under general supervision, the Business Analyst (Claims) will identify and design solutions within Claims Administration processes. The incumbent will interpret regulatory letters and memos to identify the impact on claims processes. The incumbent will be responsible for implementation of changes through project management, system configuration and User Acceptance Testing (UAT). The incumbent will work independently and perform more complex analytical and administrative responsibilities. The incumbent will exercise discretion and judgment and may coordinate a function and the work of others within the program or representing the program/project. Position Information: 
<ul>
<li>Department: Claims Administration </li>
<li>Salary Grade: 310 - $72,096 - $115,353 ($34.66 - $55.4582) </li>
<li>Work Arrangement: Full Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>95% - Program Support
<ul>
<li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Works in conjunction with the Claims Administration team, Contracting, Provider Relations, Coding Initiatives and/or Information Technology to implement benefit or process changes that impact system configuration due to federal and state notices.</li>
<li>Performs system research and testing to ensure regulatory, coding, contract updates and configuration changes produce expected results; ensures that all documentation accurately reflects the current status of changes and outstanding issues identified during testing.</li>
<li>Creates business user test scenarios and testing schedules, including time estimates and deadlines, monitors milestone completion, tracks all phases of testing and provides timely reporting of issues that impact the testing progress.</li>
<li>Communicates to the Claims Administration management team, training and staff regarding any system enhancements or changes, including any process deficiencies identified from claims look-back analysis and UAT.</li>
<li>Assists the Claims Administration management team in identifying training and development of desktop procedures and policies for the Medi-Cal and Medicare lines of business impacted by system and/or regulatory changes.</li>
<li>Provides analytical support and technical expertise on requests for information from executives, directors and other staff regarding claims.</li>
<li>Remains updated on state, federal and commercial health care environments, identifying impacts to CalOptima Health programs and claims processes utilizing MedLearn, Centers for Medicare &amp; Medicaid Services (CMS) Updates, Medi-Cal Provider Bulletins, Medi-Cal manuals and Industry Collaboration Effort (ICE).</li>
<li>Reviews ad-hoc analysis and generates reports as requested.</li>
<li>Collaborates with Claims Administration management process improvement, project management and Training Program Coordinator to identify process improvement opportunities.</li>
<li>Partners with trainer and Claims Administration management team to create or update document processes and procedures.</li>
<li>Serves as subject matter expert with end-to-end claims adjudication/processing.</li>
<li>Facilitates communication on claims related topics. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in business administration, management or related field PLUS 2 years of both Medicare and Medi-Cal claims adjudication experience required, including experience with Current Procedural Terminology (CPT-4), Healthcare Common Procedure Coding System (HCPC) coding or International Classification of Diseases (ICD-10); 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.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>N/A</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>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.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 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 our Benefits &amp; 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, 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. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6372575&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is July 22, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health 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 Health 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 at (714) 246-8400 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. To apply, please visit: <a href="https://apptrkr.com/6372575" target="_blank">https://jobs.caloptima.org/jobs/business-analyst-claims-505-city-parkway-west-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-e67e1e573a7a6948a011a0304b064368

Business Analyst (Claims)

Manager Grievance &amp; Appeals (Provider Services) CalOptima CalOptima Health is seeking a highly motivated an experienced Manager, Grievance &amp; Appeals (Provider Services) to join our team. The Manager Grievance &amp; Appeals (Provider Services) will provide daily oversight and technical management for provider services, including provider disputes, provider grievances and provider appeal to ensure compliance with state, federal and accreditation standards applicable to CalOptima Health. The incumbent will work with CalOptima Health management staff and other affiliated health networks with a close interface to the program and process, including areas such as Utilization Management, Claims Administration, Delegation Oversight, Quality Improvement and health network relations. The incumbent will research complex claims problems, isolate root causes and partner with various entities for resolution. The incumbent will communicate with all levels of internal staff, regulatory agencies, health networks, providers, vendors, community-based organizations and medical groups. Position Information: 
<ul>
<li>Department: GA - Provider Disputes </li>
<li>Salary Grade: 315 - $109,892 - $175,827 ($52.83 - $84.5322) </li>
<li>Work Arrangement: Partial Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>50% - Program Oversight
<ul>
<li>Identifies and analyzes trends, collaborates with the Director to provide trends and makes recommendations for improvement.</li>
<li>Stays current on the local, state and federal health care environment, identifying issues that may impact CalOptima Health's programs as they relate to claims, provider disputes, grievances and provider appeals.</li>
<li>Develops, implements, maintains and reviews the adequacy of the CalOptima Health provider grievance systems, reporting, policies and functions to achieve stated goals, including, but not limited to, complaint resolution and timely responsiveness for all lines of business, to ensure compliance with all relevant regulatory requirements pertaining to provider disputes.</li>
<li>Works with the Audit and Oversight department and key departments to ensure internal departments and external partners (e.g., health networks and delegates) are up to date with regulatory, departmental and organizational changes impacting the grievance and appeals processes.</li>
<li>Ensures timely and effective data collection, summarization, integration and reporting, including, but not limited to, productivity, status and trend reports for specific committees such as the Quality Improvement Committee, Grievance and Appeals Committee, Quality Assurance Committee of the Board of Directors and other ad hoc reporting as required.</li>
<li>Serves as CalOptima Health's primary point of contact and subject matter expert related to provider services (disputes, grievances and appeals).</li>
<li>Participates in Department of Managed Healthcare (DMHC), Department of Health Care Services (DHCS) and Centers for Medicare and Medicaid (CMS) audits related to area of responsibility for all CalOptima Health programs. </li>
</ul>
</li>
<li>45% - Leadership
<ul>
<li>Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.</li>
<li>Manages, hires, mentors and develops department staff.</li>
<li>Oversees the development and maintenance of internal policies and procedures and desktops to ensure compliance with all state and federal regulations for multiple lines of business.</li>
<li>Manages and makes recommendations on the development and maintenance of an effective dispute, appeals and grievance process and systems consistent with CalOptima Health policies and stated goals, including, but not limited to mechanisms to monitor provider disputes, grievances and appeals involving Legal, DMHC, DHCS, Independent Medical Review, Medi-Cal State Hearings, Office of Administrative Hearings and Appeals, CMS and external review agencies for CMS.</li>
<li>Partners with the management to ensure appropriate training and auditing tools are developed and maintained for the department. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in business administration, nursing, healthcare administration or related field PLUS 3 years of health care management experience in a related area of responsibility (provider disputes and appeals, claims administration, appeals and grievances) 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. </li>
<li>3 years of leadership experience required. </li>
<li>Experience in health maintenance organization, Medi-Cal/Medicaid, Medicare Advantage, Medicare Part D, Special Needs Plans, Medicare-Medicaid Plans and/or the Program of All-Inclusive Care for the Elderly required.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Experience with process improvement implementation.</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>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.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 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 our Benefits &amp; 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. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6357344&amp;targetURL=https://alliantbenefits.cld.bz/24caloptimacabenguide" target="_blank">2024 CalOptima Health Benefits Guide</a> and our <a href="https://apptrkr.com/get_redirect.php?id=6357344&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is July 16, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health 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 Health 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 at (714) 246-8400 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. To apply, please visit: <a href="https://apptrkr.com/6357344" target="_blank">https://jobs.caloptima.org/jobs/manager-grievance-appeals-provider-services-505-city-parkway-west-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-cf7b2c04c4b10840a8654602344b5194

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