Claims Representative

***** HealthcareJob ***** Claims Resolution Specialist/ Claims Customer Service Representative***** 06 MonthsStart ***** ASAP***** 505 City Parkway West, CA 92868 Orange CA ( 100% Onsite )Position ***** ContractInterview ***** Web Interview**The Claims Resolution Specialist will be the first line of contact for CalOptima Health providers. The incumbent will assist providers with questions related to the payment of claims and resolution of claims payment issues.** The position is a phone position requiring the candidates to answer calls for 7.5 hours a day.This is not an Examiner/Adjuster position.Duties & **80% - Claims SupportResponds and researches issues on provider questions regarding claims payments, denials, resolves claim issues, contractual and/or CalOptima Health agreements, established payment methodologies, division of financial responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.Follows up with providers as needed.15% - Administrative SupportParticipates 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.Ensures accurate and timely documentation regarding all issues, and/or inquiries are entered in Facets.Routes escalated calls to the appropriate departments and/or management.Minimum **High School diploma or equivalent required.2 years of experience in claims resolution required.1 year of call center experience with high call volumes or customer service experience required.1 year of HMO, Medi-Cal/Medicaid and healthcare/managed care experience 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.

Created: 2025-07-04