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Actuarial Analyst Sr CalOptima Join Us - Where Your Talent Meets Opportunity. We're Better Together The Team You'll Join We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a Actuarial Analyst Sr and help shape the future of healthcare where you'll be an integral part of our Financial Analysis team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. You will perform actuarial analysis on projects and support the Financial Analysis and other departments within CalOptima Health. You will also develop and design reports, create and maintain databases to support the business requirements of the team and continually improve data acquisition and reporting methods. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 
<ul>
<li>95% - Actuarial Analysis 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>Prepares, analyzes and reports the monthly Incurred But Not Reported (IBNR) reserve estimate.</li>
<li>Prepares the semi-annual Chronic Illness &amp; Disability Payment System (CDPS) risk score and analyzes and reports the financial impact for the risk score adjusted capitation rate.</li>
<li>Prepares the annual rate development template/bid for all lines of business.</li>
<li>Generates and analyzes monthly enrollment, claims and utilization reports.</li>
<li>Provides support to the Accounting department in preparing reports related to claims data and/or reserve estimation for internal and external auditors.</li>
<li>Designs reports from the data warehouse as needed and ensures data integrity.</li>
<li>Analyzes and assists in making recommendations regarding the monthly IBNR reserve estimate and the financial aspects of certain major policy issues.</li>
<li>Cross-trains as backup for various departmental functions.</li>
<li>Supports with ad-hoc analysis requests. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li> Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Do You Have What the Role Requires? 
<ul>
<li>Bachelor's degree in actuarial science, business administration, finance, economics, mathematics or other related field PLUS 2 years of actuarial 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>
<li>2 actuarial exams with passing scores required.</li>
</ul>
 You'll Stand Out More If You Possess the Following: 
<ul>
<li>Master's degree in actuarial science, business administration, finance, economics, mathematics or other related field. </li>
<li>Experience with managed health care programs and financial modeling.</li>
</ul>
 What the Regulatory Agencies Need You to Possess? 
<ul>
<li>N/A</li>
</ul>
 Your Knowledge &amp; Abilities to Bring to this Role: 
<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>
 Your 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>
 Ways We Are Here For You 
<ul>
<li>You'll enjoy competitive compensation for this role.
<ul>
<li>Our current hiring range is: Pay Grade: 312 - $84,092 - $134,548 ($40.43 - $64.6865). 
<ul>
<li>The base pay offered will take into account internal equity and also may vary depending on the candidate's job-related knowledge, skills, and experience among other factors. </li>
</ul>
</li>
</ul>
</li>
<li>This position is approved for Partial Telework (**If the position is Telework, it is eligible in California only**) </li>
<li>A <a href="https://apptrkr.com/get_redirect.php?id=6631744&amp;targetURL=https://www.caloptima.org/en/careers#benefits" target="_blank">comprehensive benefits package</a> </li>
<li>CalPERS pension program and additional retirement packages. </li>
<li>Additional benefits and perks including:
<ul>
<li>A generous PTO program</li>
<li>A quality work life balance</li>
<li>Various wellness programs</li>
<li>Tuition Reimbursement</li>
<li>Professional development opportunities</li>
<li>Career development opportunities</li>
<li>Flexible scheduling</li>
<li>And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.</li>
</ul>
</li>
</ul>
 Our 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>
 Why Join Us? We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare. What's Your Next Step? All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is October 21, 2025 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. Our Commitment to You Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet. We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. 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/6631744" target="_blank">https://jobs.caloptima.org/jobs/actuarial-analyst-sr-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-dab3e22b91f8d14296efc9847957c05a

Actuarial Analyst Sr

Claims Examiner CalOptima Join Us - Where Your Talent Meets Opportunity. We're Better Together The Team You'll Join We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a Claims Examiner and help shape the future of healthcare where you'll be an integral part of our Claims Administration team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. You will be responsible for analyzing and validating claim data elements and claims processing. You will also be responsible for adhering to the regulatory and internal processing guidelines in conjunction with CalOptima Health policies and procedures related to claims adjudication. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 
<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>
 Do You Have What the Role Requires? 
<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>
 You'll Stand Out More If You Possess the Following: 
<ul>
<li>Experience processing online claims in a managed care environment. </li>
<li>Experience processing Medi-Cal claims.</li>
</ul>
 What the Regulatory Agencies Need You to Possess? 
<ul>
<li>N/A</li>
</ul>
 Your Knowledge &amp; Abilities to Bring to this Role: 
<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>
 Your 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>
 Ways We Are Here For You 
<ul>
<li>You'll enjoy competitive compensation for this role.
<ul>
<li>Our current hiring range is: Pay Grade: 301 - $47,840 - $64,584 ($23.00 - $31.0500). 
<ul>
<li>The base pay offered will take into account internal equity and also may vary depending on the candidate's job-related knowledge, skills, and experience among other factors. </li>
</ul>
</li>
</ul>
</li>
<li>This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**) </li>
<li>A <a href="https://apptrkr.com/get_redirect.php?id=6597023&amp;targetURL=https://www.caloptima.org/en/careers#benefits" target="_blank">comprehensive benefits package</a> </li>
<li>CalPERS pension program and additional retirement packages. </li>
<li>Additional benefits and perks including:
<ul>
<li>A generous PTO program</li>
<li>A quality work life balance</li>
<li>Various wellness programs</li>
<li>Tuition Reimbursement</li>
<li>Professional development opportunities</li>
<li>Career development opportunities</li>
<li>Flexible scheduling</li>
<li>And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.</li>
</ul>
</li>
</ul>
 Our 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>
 Why Join Us? We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare. What's Your Next Step? All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is October 7, 2025 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. Our Commitment to You Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet. We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. 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/6597023" target="_blank">https://jobs.caloptima.org/jobs/claims-examiner-505-city-parkway-west-california-united-states-8b27f2ca-4a01-483b-a5da-660ffd1c9900</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-b6d0e4888401e44cadc100cbc6d1fb7d

Claims Examiner

Lead Decision Support Analyst (Principal Financial Analyst) CalOptima CalOptima Health is seeking a highly motivated Lead Decision Support Analyst (Principal Financial Analyst) to join our team. The Principal Financial Analyst (Decision Support) will be responsible for providing highly complex analysis, guidance and expert knowledge on health care finance for various departments within CalOptima Health. The incumbent is a sought-out expert and company-wide resource on matters of health care finance. Working independently, the incumbent will lead complex large-scale analytical initiatives, develop report suites and financial models used to forecast medical cost trends. The incumbent will provide expertise for provider contract negotiations, assess actuarial rate development studies, participate in annual budgeting functions, lead ad-hoc teams and serve as a subject matter expert to staff and other consultants within the department. The incumbent will evaluate high visibility complex issues, perform detailed analysis and communicate well reasoned, thorough solutions to all levels of management within CalOptima Health. The incumbent will work with large amounts of claims, enrollment and provider data. Position Information: 
<ul>
<li>Department: Financial Analysis </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>95% - Financial 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>Shares expert knowledge, mentors, trains and serves as a lead for analytical staff.</li>
<li>Serves as a subject matter expert in the following areas: Medi-Cal provider rate methodology, Medicare provider rate methodology, Department of Health Care Services (DHCS) revenue, Centers for Medicare &amp; Medicaid Services-Medicare Advantage (CMS-MA) revenue, population health member cohort identification, industry standard approaches to health care cost service categorization and metrics.</li>
<li>Forms and leads ad-hoc teams on key initiatives.</li>
<li>Provides expertise and analyses around risk adjustment.</li>
<li>Leads in the design, development, implementation and maintenance of report suites and dashboards for all levels of CalOptima Health management.</li>
<li>Researches, assesses and develops advanced tools, models, reports and approaches to increase accuracy and timeliness of data-driven work projects.</li>
<li>Develops medical expense, revenue and enrollment projections to support the budget process.</li>
<li>Develops financial models and reports to support provider contract negotiations.</li>
<li>Develops return on investment and business case analyses for program initiatives under consideration by management.</li>
<li>Provides clinical and utilization analysis to assist Medical Management with improving outcomes and quality of care for CalOptima Health members.</li>
<li>Collaborates with the Data Warehouse team to design and recommend improvements to the data warehouse. </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, finance, economics, actuarial sciences or related field PLUS 8 years of financial analysis experience in managed care 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>5 years of experience in Provider Contract Modeling, Provider Rate Analysis and/or Managed Care Contracting in a health care setting required. </li>
<li>1 year of experience writing SQL required.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>5 years of analytical experience working with Medi-Cal and/or Medicare payer information. </li>
<li>Experience in an Independent Physician Association (IPA), hospital or health plan setting. </li>
<li>Intermediate to Advanced proficiency in Excel. </li>
<li>Experience with DHCS rate development and/or Medicare Advantage bid process.</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=6600979&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 September 2, 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/6600979" target="_blank">https://jobs.caloptima.org/jobs/lead-decision-support-analyst-principal-financial-analyst-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-15ab6f518e31d340afef5402c05bff17

Lead Decision Support Analyst (Principal Financial Analyst)

<h3>Job Description</h3>
Job DescriptionDescription:
*Must be located in Oregon*
 
POSITION SUMMARY:
The Claims Adjuster is responsible for managing workers compensation claims and assisting the process of determining benefits due the injured worker, ensure ongoing adjudication of claims within company standards and industry best practices and comply with all statutory and regulatory requirements for the administration of workers compensation benefits on behalf of the Company.
 
RESPONSIBILITIES:
<ul>
<li>New Claims: All new lost time claims require an initial contact with the employer, the injured worker and the medical provider. This must be done within 24 hours of receipt of the claim or notification of a claim. </li>
<li>Ensure that all claim determinations and payments are completed timely including but not limited to, acceptance/denial letters, wage determination letters including required enclosures and appeal forms. In jurisdictions requiring the letters be provided in Spanish and English the adjuster is responsible to make sure all letters are completed.</li>
<li>The initial payment of TTD is to be completed within 14 days from the receipt of an accepted claim. Wage information is to be solicited from the employer and either an average weekly wage or average monthly (jurisdiction dependent) be established and the information documented in Origami(Claims System). In the event actual payroll documentation cannot be obtained from the employer an “estimated wage” is established and a payment reconciliation is done when the verified wage is secured. Initial compensation benefits should NOT be delayed due to the failure of the employer to provide wage documentation.</li>
<li>Timely claims determinations for all services including but not limited to: acceptance, denials, authorizations for treatment, benefit payment start, termination are to be included within the statutory or regulatory time frames of the jurisdiction. Denials requiring certified mailing are to be completed timely with appropriate tracking.</li>
<li>Regulatory notices are to be completed timely when required by jurisdictions.</li>
<li>Approvals and denials of medical bills should be completed within 24 hours of receipt so bills can be repriced and paid timely.</li>
<li>Identify the medical providers and medical treatment plan and ensure timely and appropriate medical care is provided to the injured worker. In cases requiring complex or unusual medical care a nurse case manager is to be assigned to facilitate the timely and appropriate care.</li>
<li>All communications with all parties and reference to all determinations and correspondence are to be included in the claim notes of Origami (Claim System). Each office is “paperless” offices, and all documents need to be scanned and added to the claim claims system and a claim note generated. notes. </li>
<li>Manage the legal aspects of the claim and appropriately assign and direct designated attorneys. </li>
<li>Assign claims for investigations, including surveillance, medical surveys and social media checks when required and seek supervisor support on related questions.</li>
<li>Ensure that all bills for various expenses, including legal bills, managed care bills and similar expenses are paid timely or direct claims assistants to pay such when appropriate.</li>
<li>Answer phone calls immediately when in the office. Return all calls and voice mail messages with 24 hrs. Respond to all e-mails when required within 24 hrs.</li>
<li>Direct claims assistants to facilitate adjuster assignments as required. This includes directing clerical staff in duties such as copying documents, scheduling medical appointments for injured workers and filing of documents. Coordinate assignments with the supervisor of the assistants.</li>
<li>Establish a Plan of Action (POA) on each claim and update the POA monthly.</li>
<li>Monitor claims for reinsurance/excess insurance reporting and provide initial reports and quarterly updates on all claims meeting reporting requirements.</li>
<li>Performs other activities, assignments and duties as assigned.</li>
<li>Eligible for remote or hybrid work arrangement.</li>
</ul>
 
Requirements:
QUALIFICATIONS:
<ul>
<li>High school diploma or GED required</li>
<li>Bachelor’s degree or equivalent experience preferred</li>
<li>2-3 years’ claims experience preferred</li>
<li>Insurance industry knowledge preferred</li>
<li>Excellent analytical skills and verbal and written communication skills</li>
<li>Strong organizational skills</li>
<li>Strong oral and written communication skills</li>
<li>Located in Oregon</li>
</ul>

Claims Adjuster

<h3>Job Description</h3>
Job Description:
We have an immediate opening in our home office located in Hanover, Maryland. This inside position is responsible for conducting liability and coverage investigations, bodily injury and property damage evaluations, as well as successfully negotiating the settlement of first and third party injury and property damage claims.
Qualifications:
<ul>
<li>Qualified applicants should have 2 to 5 years of experience adjusting automobile accident claims.</li>
<li>Bachelor’s Degree or equivalent industry experience. Attention to detail and ability to multi-task.</li>
<li>Excellent communication, organizational, and customer service skills.</li>
<li>A high degree of motivation and team orientation.</li>
<li>Proficiency with property damage estimates.</li>
<li>PC experience with knowledge of Word, Excel, and Outlook.</li>
</ul>

<h3>Job Description</h3>
Job Description
<ul>
<li>Location: Remote</li>
<li>Duration: 5 Months (Contract to Hire)</li>
<li>Pay Rate: $21/h</li>
</ul>
 
About the Role
We are seeking Claims Adjuster to join our remote team supporting Cigna / Evernorth. This is an excellent opportunity for individuals with strong customer service and insurance experience who are interested in transitioning to a permanent role.
You will handle inbound calls from providers and members, primarily regarding claims, eligibility, and benefits. This role requires excellent communication, problem-solving, and multitasking skills, as well as the ability to navigate multiple systems while delivering first-call resolution and professional customer service.
 
Key Responsibilities
<ul>
<li>Answer an average of 45 inbound calls daily regarding claims, eligibility, and benefits.</li>
<li>Assist providers and members with claim status, billing protocols, and contract-related inquiries.</li>
<li>Process requests such as claim reprocessing, duplicate EOBs, or payment reissues.</li>
<li>Update provider demographic information and submit escalations when necessary.</li>
<li>Document and resolve inquiries accurately, ensuring compliance and first-call resolution.</li>
<li>Make occasional outbound calls to follow up on claim or provider relation issues.</li>
</ul>
 
Qualifications
<ul>
<li>Bachelor’s degree required.</li>
<li>Prior experience in customer service (insurance industry strongly preferred).</li>
<li>Strong interpersonal and communication skills (written and verbal).</li>
<li>Ability to multitask while using multiple applications.</li>
<li>Strong organizational skills and attention to detail.</li>
<li>Technical proficiency with PC systems and applications.</li>
</ul>
Must have reliable high-speed internet at home (equipment will be provided).
Company Description• Come get Swoon’d!! \t• Swoon handles the staffing need of over 80 Fortune 500 clients. \t• We have won Best and Brightest Companies to Work for in the Nation Award 6 years in a row. Swoon was also awarded the Inc. 5000 Fastest Growing Private Companies in the US from 2016 – 2020. 
<h3>Company Description</h3>
• Come get Swoon’d!!\r\n\t• Swoon handles the staffing need of over 80 Fortune 500 clients.\r\n\t• We have won Best and Brightest Companies to Work for in the Nation Award 6 years in a row.\r\nSwoon was also awarded the Inc. 5000 Fastest Growing Private Companies in the US from 2016 – 2020.

<h3>Job Description</h3>
Job Description
CURE Auto Insurance is a leading direct writer of auto insurance in New Jersey, Pennsylvania, and Michigan. CURE offers a great working environment, competitive salary, and comprehensive benefits package which includes health and dental coverage, life and disability insurance, 401k with generous company match, and much more!
 
This position is responsible for handling Property and Casualty Auto Insurance claims. Candidates should have at least 2 years of experience handling auto insurance claims.
 
Essential Job Functions: 
<ul>
<li>
Investigate validity of claims, evaluate policy coverages, and determine if any special investigation unit referrals are warranted. Set expectations, develop a plan of action, and perform all tasks according to company set guidelines.
</li>
<li>
Make prompt contact with policyholders and other appropriate parties involved in the loss to obtain the necessary documentation, conduct recorded statements, etc. 
</li>
<li>
Establish initial reserves based on gathered information and adjust as appropriate through completion of assigned claim.
</li>
<li>
Negotiate timely and appropriate settlements with claimants, attorneys, or other parties. Issue proper and accurate payments as needed.
</li>
<li>
Identify questionable risks, red flags, fraud indicators and alert the special investigation unit when applicable.
</li>
<li>
Establish and maintain an organized diary system to ensure all claims are properly and adequately handled in a timely manner.
</li>
<li>
Adhere to all state/local regulations including the NJ/PA/Michigan Unfair Claims Practices and Guidelines.
</li>
<li>
Other responsibilities or duties as assigned.
</li>
</ul>
 
Experience/Qualifications:
<ul>
<li>
A minimum of 2 years Auto Claims handling experience
</li>
<li>
Ability to communicate clearly, professionally, and provide superior customer service over the phone and through written correspondence.
</li>
<li>
Strong organizational and time management skills.
</li>
<li>
Excellent analytical, investigative, and settlement skills.
</li>
<li>
Proficient with Microsoft Office and various other computer skills with the ability to learn and utilize new computer systems and other technologies.
</li>
</ul>
 
Benefits
<ul>
<li>Medical, dental, and vision insurance</li>
<li>401(k) with employer match</li>
<li>Paid time off (vacation, sick leave, and holidays</li>
<li>FSA and HRA</li>
<li>Parental leave opportunities</li>
<li>Life and Disability Insurance</li>
<li>Employee Assistance Programs (EAP)</li>
<li>Discounted tickets to CURE Arena in NJ</li>
<li>Voluntary Benefits (Pet Insurance, ID &amp; Fraud, Accident &amp; Illness, and more!)</li>
</ul>
 
Physical Actions/Environment: Required job duties consist of prompt and regular attendance, ability to frequently move about the office to coordinate work with others; standing, sitting and typing for extended periods; and lifting and/or carrying up to 5 lbs. Ability to frequently communicate with others in-person, on the phone/virtually, and in writing. Ability to read, understand, process and evaluate large amounts of technical information and make related, informed decisions. 
 
Starting Salary: 52,000 - 90,000 depending on experience 
 
Schedule: 8:30 AM - 5:00 PM; We offer a hybrid work schedule: team members work onsite 4 days per week and have the flexibility to work remotely 1 day per week.
 
Location: Detroit, MI or Princeton, NJ
 
We recruit, hire, employ, train, promote, and compensate individuals based on job-related qualifications and abilities. We respect the dignity and worth of each individual and are committed to an employment environment that is free from all forms of employment discrimination. 
 
CURE Auto Insurance provides equal employment opportunities to all employees and applicants for 
employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, pregnancy, gender identity or expression, or any other characteristic protected by federal, state or local laws.
 
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
 
Disclaimer: This job description reflects management's assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned. This job description may be subject to change at any time.
 
Applicants must be authorized to work for ANY employer in the U.S. We are unable to sponsor or take over sponsorship of an employment Visa at this time.

<h3>Job Description</h3>
Job Description
Providence Staffing's client, a respected personal injury law firm in Providence, RI, is seeking a detail-oriented and experienced Personal Injury Plaintiff Claims Adjuster to join their team. This role is critical in managing, evaluating, and negotiating insurance claims on behalf of injured plaintiffs. The ideal candidate will hold an active adjuster license and possess deep knowledge of insurance practices, liability assessments, and client advocacy.
Key Responsibilities:
<ul>
<li>Conduct thorough investigations of personal injury claims by reviewing police reports, medical records, photographs, and witness statements.</li>
<li>Interview clients, witnesses, and relevant third parties to establish timelines and clarify the facts of each incident.</li>
<li>Evaluate bodily injuries and damages, including wage loss and future medical expenses, in consultation with healthcare professionals as needed.</li>
<li>Determine liability by applying relevant laws and analyzing available evidence.</li>
<li>Negotiate settlements with insurance companies to secure fair compensation, providing detailed responses to insurer offers and lowball settlements.</li>
<li>Maintain accurate, well-documented claim files including notes on investigations, interviews, communications, and settlement negotiations.</li>
<li>Ensure all claims handling complies with state laws, insurance regulations, and internal firm policies.</li>
<li>Collaborate with attorneys as needed to support litigation strategy and trial preparation.</li>
<li>Communicate empathetically with clients throughout the claims process, ensuring they are informed, supported, and guided.</li>
</ul>
Required Qualifications:
<ul>
<li>Active state-issued insurance adjuster license (must be valid at the time of application and maintained throughout employment).</li>
<li>Proven experience managing personal injury claims, ideally on the plaintiff side or as an independent adjuster.</li>
<li>Strong knowledge of insurance policies, coverage interpretation, and personal injury legal principles.</li>
<li>Skilled negotiator with excellent written and verbal communication skills.</li>
<li>Analytical thinker with the ability to review complex data and make sound decisions.</li>
<li>Self-motivated and capable of handling multiple cases in a fast-paced, deadline-driven environment.</li>
</ul>
Preferred Skills:
<ul>
<li>Experience conducting field investigations, including site visits and evidence collection.</li>
<li>Background working with both direct insurance carriers and independent adjusting agencies.</li>
<li>Bilingual or multilingual skills are a plus, particularly for firms with a diverse client base.</li>
</ul>
Working Conditions:
<ul>
<li>Hybrid schedule available (combination of in-office and remote work).</li>
<li>Flexible, supportive work environment focused on collaboration and client-centered results.</li>
</ul>
If you are a licensed adjuster who thrives in advocacy-based claims handling and wants to make a direct impact in clients' lives, we encourage you to apply and join a mission-driven legal team.

<h3>Job Description</h3>
Job DescriptionDescription:
Please note that this job is located in Victoria, TX with Apex Protection Plan.
The Apex Protection Plan has the following duties:
<ul>
<li>Handles claims related phone calls from Dealers and Repair Facilities per work schedule performing within company standards</li>
<li>Monday through Friday schedule in an office environment</li>
<li>Follows proper claims procedures as outlined in training and feedback provided by management</li>
<li>Master understanding of contract terms and conditions</li>
<li>Understand Exceptions based upon dealership, agent, or client as noted in system</li>
<li>Support other team members in assisting customers when situation requires involvement</li>
<li>Escalates “Hot Issues” to team lead, supervisor, or managers when unable to resolve satisfactorily</li>
<li>Notify Supervisor of any claims in which possible fraud is suspected</li>
<li>Participates in all training as required to perform the duties of the role</li>
<li>Takes initiative to resolve an issue rather than allow an issue to continue</li>
<li>Performs other related duties as required and/or assigned</li>
</ul>
Job Requirements:
<ul>
<li>High School Diploma or equivalent</li>
<li>Minimum of one year of experience within Automotive Service Industry preferred, specifically the Service Advisor position</li>
<li>Must have strong computer skills and the ability to troubleshoot and service policy issues</li>
<li>Must be proficient in Windows and MS-Office Products</li>
<li>Strong analytical and problem solving skills. Superior verbal/written skills and communications skills</li>
<li>Good punctuation, spelling, mathematical, grammar and attention to detail</li>
<li>Strong interpersonal skills essential</li>
<li>Ability to exercise sound judgment when interacting with customers</li>
<li>Must be authorized to work in the U.S or Canada</li>
<li>Must be able to successfully pass a background check</li>
<li>Located in Victoria, TX</li>
</ul>
Preferences:
<ul>
<li>Experience in customer service, insurance claims, or call/claims center environment</li>
<li>College Degree or equivalent work experience</li>
</ul>
Requirements:

<h3>Job Description</h3>
Job DescriptionBenefits: 
<ul>
<li>401(k) matching</li>
<li>Company parties</li>
<li>Competitive salary</li>
<li>Dental insurance</li>
<li>Free food &amp; snacks</li>
<li>Health insurance</li>
<li>Opportunity for advancement</li>
<li>Paid time off</li>
<li>Vision insurance</li>
</ul>
 Claims Advocate Worthy Insurance Group, a national Property &amp; Casualty Insurance Brokerage located in Skokie, IL, is looking for a Claims Advocate to join our Risk Management team. Gain superb, well-rounded training and experience in all facets of insurance: claims, coverages, sales, and the law. As Claims Advocate, you will be exposed to a wide variety of fascinating matters from medical malpractice lawsuits to federal criminal investigations to ransomware cyber-attacks. You will have the chance to cultivate the skills that lead to success in all areas of business. Key Responsibilities 
<ul>
<li>In-take and report all claim to carriers, track when acknowledgments are received and when the first contact is made from adjuster to insured</li>
<li>Explain the claims process to insureds in an effective and detailed manner</li>
<li>Facilitate discussions between claims adjusters and insureds and monitor all claim activity and follow up with all relevant parties ensure a seamless process</li>
<li>Review carrier reserve amounts throughout the claims process to ensure accuracy and update the insured as necessary</li>
<li>Provide regular updates to insureds corporate entities with full updates regarding claims</li>
<li>Assist Account Managers in gathering claim information as needed for marketing and renewals</li>
<li>Assist in identifying loss trends in reported claims and communicating with the Loss Control and Account Management teams to address them</li>
<li>Maintain and document all claim activity within agency management system (EPIC)</li>
<li>Utilize and facilitate effective communication both internally and externally, including but not limited to clients, claims adjusters, Account Managers, Producers, and the remainder of the Risk Management Team</li>
<li>Be a collaborative and flexible member of the Risk Management Team</li>
<li>Must be able to take initiative and research relevant statutes as applies to claims</li>
</ul>
Qualifications Preferred 
<ul>
<li>College Degree OR equivalent work experience</li>
<li>3+ years of Property &amp; Casualty Insurance experience</li>
<li>Applied Epic -Property &amp; Casualty agency management system.</li>
<li>Claims handling experience</li>
<li>Paralegal background/experience</li>
</ul>
Required 
<ul>
<li>Proficient with computers and standard Microsoft software packages especially Excel</li>
<li>Excellent oral and written communication</li>
<li>Creative problem-solving skills</li>
<li>Superior organizational skills</li>
<li>Exceptional time management and attention to detail</li>
</ul>
Who We Are: Worthy Insurance focuses on providing creative insurance solutions to the healthcare, social service, and real estate industries. Taking care of people and their businesses while protecting their livelihoods and assets is at the core of what we do. Worthy empowers our employees to grow with personal and professional development opportunities. We work hard, but we love to have fun! Worthy employees enjoy: 
<ul>
<li>Generous Paid Time Off (PTO)</li>
<li>401k with company match</li>
<li>Health, Dental, and Vision Insurance</li>
<li>Onsite Gym Membership</li>
<li>Insurance education bonus program</li>
<li>Paid Time Off for Volunteering</li>
</ul>

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