• Bachelor's degree in Healthcare Administration or relevant field, or the equivalent combination of education and/or related experience required.
• 2 years of medical health claims processing experience required.
• 2 years audit experience in Audit & Oversight, Claims Administration, Customer Service, or applicable area required.
• Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal Fee schedule, All Patient Defined Diagnosis Related Group (AP-DRG), Ambulatory Payment Classification (APC), Healthcare Common Procedure Coding Systems (HCPCS) codes.
• International Classification of Diseases (ICD)-10, Current Procedure Terminology (CPT), and Revenue Codes.
• Managed Care compliance for Medi-Cal and Medicare.
• Center for Medicare & Medicaid Services (CMS) and Medi-Cal/Department of Healthcare Services (DHCS) claims processing regulations.
• Fundamental principles of writing and grammar, including proper report and correspondence format, correct spelling, and proper work usage, grammar, punctuation, and sentence structure.
Department(s): Claims Administration
Reports to: Manager, Claims
FLSA status: Non-Exempt
Salary Grade: F - $24.52- $35.43 ($51,000 - $73,700)
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.
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