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Direct Claims Jobs in California (NOW HIRING)

Insperity

Director of Claims- Healthcare

Los Angeles, CA · On-site

$130K - $160K/yr

The Director of Claims is a senior leadership role responsible for the strategic direction, operational management, and regulatory oversight of the Claims Department. This position oversees all ...

Insperity

Director of Claims- Healthcare

Chatsworth, CA · On-site +1

$130K - $160K/yr

Description & Requirements Director of Claims- Healthcare Preferred IPA of California is committed to delivering exceptional care management, care coordination, and claim processing services that ...

Resilienceforward

Head of Risk Management

Los Angeles, CA · On-site

$250 - $500/hr

Direct claims strategies and outcomes, including the management of TPAs, major and complex claims, and an effective return‑to‑work program. Program design, innovation, and alternative risk ...

Netflix

Head of Risk Management

Los Angeles, CA

Direct claims strategies and outcomes, including management of TPAs, major and complex claims, and an effective returntowork program. Program Design, Innovation & Alternative Risk Financing Develop ...

Netflix, Inc.

Head of Risk Management

Los Angeles, CA · On-site

$350 - $600/hr

Direct claims strategies and outcomes, including management of TPAs, major and complex claims, and an effective return‑to‑work program. Program Design, Innovation & Alternative Risk Financing ...

KHS

Claims Trainer

Bakersfield, CA · On-site

$28.62 - $36.49/hr

The Claims Trainer is responsible for the direct training of the Claim Examiner staff. Responsibilities include, but are not limited to, review of Claims policy and procedures to ensure staff ...

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Showing results 21-40

All JobsDirect Claims JobsDirect Claims Jobs in California

Direct Claims information

What is a direct claim?

Direct claims refer to insurance claims that are filed directly by the policyholder with their own insurance company, rather than going through a third party or the at-fault party's insurer. This process is common in situations like auto accidents, where the policyholder seeks compensation for damages or losses under their own policy. Direct claims help streamline the process, reduce delays, and ensure the policyholder receives prompt assistance and settlements. They are often associated with 'first-party' insurance coverage, such as collision, comprehensive, or health insurance claims.

Can you work remotely in direct claims jobs?

Many direct claims jobs offer remote work options, especially for roles involving claims processing, customer service, or administrative tasks. Employers may require familiarity with claims management software and good communication skills, and remote positions often involve standard office hours and secure internet connections.

Do I need a degree to be a direct claims specialist?

A degree is not typically required to become a direct claims specialist, but relevant experience, knowledge of insurance policies, and strong communication skills are important. Many employers provide on-the-job training and may prefer candidates with a high school diploma or equivalent. Certifications in insurance or claims processing can enhance job prospects.

What are some common challenges faced by professionals in direct claims roles, and how can they effectively manage these challenges?

Professionals in Direct Claims often face the challenge of balancing a high volume of claims with the need for thorough investigation and timely resolution. Managing customer expectations and handling sensitive situations, such as denied claims or complex cases, can also be demanding. Effective communication, strong organizational skills, and staying updated on policy guidelines are crucial for success. Building collaborative relationships with adjusters, underwriters, and other departments helps ensure accurate and efficient claims processing.

What are the key skills and qualifications needed to thrive as a direct claims specialist?

To thrive as a Direct Claims Specialist, you need a solid understanding of insurance policies, claims processes, and relevant legal regulations, often supported by a degree in business, finance, or a related field. Familiarity with claims management software, customer relationship management (CRM) systems, and sometimes industry certifications like AIC or CPCU is typical. Exceptional attention to detail, problem-solving abilities, and strong communication skills set top performers apart in this role. These skills and qualifications ensure claims are processed accurately and efficiently, leading to customer satisfaction and minimized risk for the insurer.

What is the difference between Direct Claims vs Claims Adjuster?

AspectDirect ClaimsClaims Adjuster
CredentialsInsurance license, knowledge of policiesInsurance license, sometimes certifications like AIC or CPCU
Work EnvironmentCustomer service, office or remoteFieldwork, office, or remote
Employer & IndustryInsurance companies, agenciesInsurance companies, third-party administrators
Search & Comparison IntentUnderstanding direct claims handlingEvaluating claims adjustment roles

Direct Claims professionals primarily handle claims directly from policyholders, focusing on processing and resolving claims within the insurance company. Claims Adjusters evaluate, investigate, and settle claims, often working in the field or remotely. Both roles require insurance licensing, but Claims Adjusters may have additional certifications. While their work overlaps in claims processing, Direct Claims roles are more customer-facing, whereas Claims Adjusters focus on assessment and negotiation.

What are popular job titles related to Direct Claims jobs in California? For Direct Claims jobs in California, the most frequently searched job titles are:
What job categories do people searching Direct Claims jobs in California look for? The top searched job categories for Direct Claims jobs in California are:
What cities in California are hiring for Direct Claims jobs? Cities in California with the most Direct Claims job openings:
Direct Claims jobs near you

Senior Claims Auditor

Astrana Health, Inc.

Monterey Park, CA • On-site

$70K - $80K/yr

Full-time

Posted 5 days ago

Job description

Senior Claims Auditor
Department: Ops - Claims Ops
Employment Type: Full Time
Location: 1600 Corporate Center Dr., Monterey Park, CA 91754
Reporting To: Randi Hanson
Compensation: $70,308 - $80,000 / year
Description
Job Title: Senior Claims Auditor
Department: Ops - Claims Ops
About the Role:We are currently seeking a highly motivated Senior Claims Auditor. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry.
What You'll Do
  • Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
  • Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit
  • Requires the ability to communicate and analyze claims processing methodologies according to CMS and DMHC guidelines
  • Respond to preliminary results by the due dates
  • Requires the ability to respond to the corrective action plan timely and address the root cause appropriately as well as remediate the deficiency
  • Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows
  • Handle complex and urgent audit projects from external provider and internal departments
  • Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests Audit Documentation/Reconciliation
  • Accurately document the underpayments and overpayments into the audit database
  • Assist management with analyzing Claim error trends
  • Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer Collaboration
  • Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution
  • Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members

Qualifications
  • A High School Diploma or Equivalent
  • At least 2 years of experience as Medical Claims Auditor or 7 years previous experience examining Claims
  • Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures required
  • Detail knowledge and understanding of Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etc
  • Detail knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
  • Possess working knowledge of NCQA, DHS and HCFA standards
  • Knowledge of medical terminology combined with detail knowledge and experience with CPT, HCPCS, DRG, REV, OPS, ASC, ICD10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC and DHS fee schedules and CMS Medicare regulatory agencies, COB and Third-Party Liability recovery
  • Must have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations
  • Must possess the ability to effectively present information and respond to questions from managers, employees, customers
  • Must possess advanced reasoning and problem-solving abilities and planning skills
  • Ability to multi-task, prioritize and work in a fast-paced environment under minimal supervision
  • Proficient in Excel to include the ability to create and revise Excel spreadsheets to provide accurate and clear reports
  • Strong independent decision-making, influencing and analytical skills
  • Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines

You're great for the role if:
  • Bachelor's degree preferred

Environmental Job Requirements and Working Conditions
  • Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.
  • The target pay range for this role is between $70,308.00 - $80,000.00. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

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