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Claims Examiner CalOptima CalOptima Health is seeking a highly motivated Claims Examiner to join our team. The Claims Examiner will be responsible for analyzing and validating claim data elements and claims processing. The incumbent will be responsible for adhering to the regulatory and internal processing guidelines in conjunction with CalOptima Health policies and procedures related to claims adjudication. Position Information: 
<ul>
<li>Department: Claims Administration </li>
<li>Salary Grade: 301 - $47,840 - $64,584 ($23.00 - $31.0500) </li>
<li>Work Arrangement: Full Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>85% - Claims Support
<ul>
<li>Performs thorough review of pending claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services.</li>
<li>Processes non-institutional claim types.</li>
<li>Corrects system generated errors manually prior to final claims adjudication.</li>
<li>Processes claims based upon CalOptima Health contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and CalOptima Health policies and procedures.</li>
<li>Analyzes and validates Medi-Cal pricing; researches, adjusts and adjudicates claims; reviews services for accurate charges and utilizes current billing code sets, including International Classification Diseases (ICD10) codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference.</li>
<li>Validates eligibility and other possible health insurance coverage on the claim.</li>
<li>Alerts manager or supervisor of more complex issues that arise.</li>
<li>Processes claim exception reports as assigned. </li>
</ul>
</li>
<li>10% - Administrative 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>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>High school diploma or equivalent PLUS 1 year of related claims processing 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.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Experience processing online claims in a managed care environment. </li>
<li>Experience processing Medi-Cal claims.</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=6329575&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 11, 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/6329575" target="_blank">https://jobs.caloptima.org/jobs/claims-examiner-505-city-parkway-west-california-united-states-fd7ed77a-73a4-4bd2-9f12-47d82ac1ed30</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-a4cc42329aeb0d40b1127d796b9ce31e

Claims Examiner

Finance: SCOR Global Life Americas Reinsurance Company seeks Director, Actuary Fin'l Dvlpmt Innovation in NY, NY to lead actuarial modeling projects at SCOR US, such as annual assumption updates &amp; quarterly in force mgmt projects &amp; be key contributor to other company-wide strategic projects. Req'mts: Bachelor's or foreign equiv in Actuarial Sci, Math, Stats or rel. field, or rel. field &amp; 5 yrs of progressively responsible exp in job offered or rel. occupation: utilizing exp w/fin'l valuation, modeling, &amp; cash flow analysis. Must be Fellow of the Society of Actuaries. Telecommuting &amp;/or work from home may be permissible pursuant to company policies. When not telecommuting, must report to work site. Offered salary is btwn $195,000 &amp; $250,000/yr. 40 hrs/wk. Please submit resume to <a href="mailto:KZAGOLSKA@scor.com" target="_blank">KZAGOLSKA@scor.com</a> &amp; indicate job code LL041825AD. No Headhunters. NO CALLS PLEASE. EOE.

Director, Actuary Fin'l Dvlpmt Innovation

At Northwestern Mutual, we are strong, innovative and growing. We invest in our people. We care and make a positive difference. 
 We are seeking an experienced professional in the Individual Disability Insurance (DI) Claims field to join our DI Claims team.&nbsp; The ideal candidate will possess extensive knowledge and experience in managing DI claims, as well as strong leadership abilities to guide and develop claim analysts by serving as a role model and resource, monitoring, and guiding claim management skills, and providing positive reinforcement through effective case management. 
 A variety of soft skills and experience may be required for the following role Please ensure you check the overview below carefully. 
 Primary Duties and Responsibilities 
<ul>
<li> Develops the technical performance of disability claim analysts by serving as a role model and resource via the following team leader responsibilities. </li>
<li> Monitors, guides, and develops the claim management skills of claim analysts. </li>
<li> Provides positive reinforcement and opportunities regarding case management through the effective handling of verbal and written referrals in accordance with divisional practices as defined by the Service Goal, Best Practices and Desk Organization guidelines. </li>
<li> Provides effective ongoing performance feedback to the individual and the manager. </li>
<li> Investigates, analyzes and makes decisions on a reduced volume of high effort non-contestable and contestable disability income claims including late claims, Disability Overhead Expense, Financial Representative, Buyout and Keyperson. </li>
<li> Uses extensive financial, medical, legal and contractual knowledge to interpret and analyze pertinent facts in making and communicating claim decisions. </li>
<li> Responsible for managing claims in litigation and referring claims to the Law Department. </li>
<li> May be called upon to represent the Company in legal matters through preparation for and participation in depositions and trials. </li>
<li> Preserves Northwestern Mutual's image and reputation in the approval or denial of benefits despite difficult and delicate circumstances. </li>
<li> Determines applicability of benefits claimed by interpreting contract provisions and maintaining consistency with our Disability Benefits claim philosophy. </li>
<li> Approval Limits Contestable and Non-Contestable $0-$11,000. </li>
</ul>
 Qualifications 
<ul>
<li> Five to seven years of experience in Individual Disability Insurance Claim handling demonstrating analytical ability, in-depth knowledge of DI policies, procedures, and regulations. </li>
<li> Independent decision-making and sound judgment in the application of guidelines. </li>
<li> Ability to collaborate within and across teams to obtain the best possible results. </li>
<li> Excellent organization and communication skills. Bachelor's Degree or equivalent work experience. </li>
</ul>
 Compensation Range: 
 Pay Range - Start: 
 $69,720.00
 Pay Range - End: 
 $129,480.00
 Northwestern Mutual pays on a geographic-specific salary structure and placement in the salary range for this position will be determined by a number of factors including the skills, education, training, credentials and experience of the candidate; the scope, complexity as well as the cost of labor in the market; and other conditions of employment. At Northwestern Mutual, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. Please note that the salary range listed in the posting is the standard pay structure. Positions in certain locations (such as California) may provide an increase on the standard pay structure based on the location. Please c lick here for additional information relating to location-based pay structures. 
 Grow your career with a best-in-class company that puts our client’s interests at the center of all we do. Get started now! 
 We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender identity or expression, sexual orientation, national origin, disability, age or status as a protected veteran, or any other characteristic protected by law. 
 If you work or would be working in California, Colorado, New York City, Washington or outside of a Corporate location, please click here for information pertaining to compensation and benefits. 
 FIND YOUR FUTURE
We’re excited about the potential people bring to Northwestern Mutual. You can grow your career here while enjoying first-class perks, benefits, and commitment to diversity and inclusion.&nbsp;
<ul>
<li>Flexible work schedules</li>
<li>Concierge service</li>
<li>Comprehensive benefits</li>
<li>Employee resource groups</li>
</ul>
PandoLogic. Keywords: Insurance Examiner, Location: Franklin, WI - 53132

DI Claims Team Cons - Team Lead

At Northwestern Mutual, we are strong, innovative and growing. We invest in our people. We care and make a positive difference. 
 Summary: 
 All potential candidates should read through the following details of this job with care before making an application. 
 Provide technical leadership and direction to the Disability Income Claims Division to ensure accurate and fair administration of claims. 
 Primary Duties &amp; Accountabilities: 
<ul>
<li> Collaborate with claims leadership to establish a strategic vision for future Disability Income (DI) claims administration, including identifying and facilitating claim handling process improvements and technological enhancements. </li>
<li> Direct and lead projects to evolve the technical guidelines and procedures that serve as the framework for DI claims administration. </li>
<li> Establish technical proficiency standards for claims administration and to support effective training, coaching, and mentoring of claims analysts and technical leaders. Provide feedback and develop the skills and expertise of team members.&nbsp; </li>
<li> Proactively work to influence and motivate others while creating a climate that fosters customer focus and continuous learning and improvement. </li>
<li> Develop and maintain claim handling standards and best practices, ensuring compliance with company philosophy, contract language and provisions, and state laws. </li>
<li> Provide expertise in handling complex, sensitive, contestable, or large benefit amount cases. Oversee claim denial and recovery processes, and manage complaints, appeals, and highly contentious claims, including disability and life waiver of premium claims. </li>
<li> Resolve claim conflicts through formal and informal dispute resolution practices. Collaborate with the Law Department on lawsuits, depositions, and trial representations. Establish negotiation parameters and exercise judgement in settlements. Serve as liaison between claim staff and the Law Department on a wide variety of legal issues. </li>
<li> Serve as a product line subject matter expert for new contract introductions and projects impacting claim handling. </li>
<li> Represent the disability claim operation within the industry and act as a liaison within the home office. </li>
</ul>
 Knowledge, Skills &amp; Abilities: 
<ul>
<li> College degree in business or related field </li>
<li> Eight to ten years of experience with insurance products and claim processes and procedures </li>
<li> Demonstrated capability as a technical expert and leader, with a proven ability to lead, mentor, and develop others, and work effectively across teams </li>
<li> In-depth knowledge of insurance products, underwriting processes, medical and financial information, claim philosophy, and claim handling practices </li>
<li> Knowledge of and experience in managing claim legal issues and the litigation process </li>
<li> Excellent judgment and decision-making skills </li>
<li> Experience in negotiation and conflict management </li>
<li> Excellent verbal and written communication skills, including those for liaising with policyowners, legal counsel, financial experts, field members, and home office personnel </li>
<li> Experience in project leadership or similar efforts </li>
</ul>
 Compensation Range: 
 Pay Range - Start: 
 $84,350.00
 Pay Range - End: 
 $156,650.00
 Northwestern Mutual pays on a geographic-specific salary structure and placement in the salary range for this position will be determined by a number of factors including the skills, education, training, credentials and experience of the candidate; the scope, complexity as well as the cost of labor in the market; and other conditions of employment. At Northwestern Mutual, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. Please note that the salary range listed in the posting is the standard pay structure. Positions in certain locations (such as California) may provide an increase on the standard pay structure based on the location. Please c lick here for additional information relating to location-based pay structures. 
 Grow your career with a best-in-class company that puts our client’s interests at the center of all we do. Get started now! 
 We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender identity or expression, sexual orientation, national origin, disability, age or status as a protected veteran, or any other characteristic protected by law. 
 If you work or would be working in California, Colorado, New York City, Washington or outside of a Corporate location, please click here for information pertaining to compensation and benefits. 
FIND YOUR FUTURE
We’re excited about the potential people bring to Northwestern Mutual. You can grow your career here while enjoying first-class perks, benefits, and commitment to diversity and inclusion.&nbsp;
<ul>
<li>Flexible work schedules </li>
<li>Concierge service </li>
<li>Comprehensive benefits </li>
<li>Employee resource groups </li>
</ul>
PandoLogic. Keywords: Insurance Examiner, Location: Franklin, WI - 53132 , PL: 597056090

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