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Program Specialist (eBusiness)

Program Specialist (eBusiness)


Job Description


Why CalOptima?

CalOptima is the single largest health plan in Orange County, serving 880,000 members, or 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. If you're looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima.


Job Summary


The eBusiness Program Specialist performs tasks relevant to existing Electronic Data Interchange (EDI) processes, web-based applications, and claims-related programs and processes. The incumbent is responsible for providing analytical reporting and administrative support to both internal and external stakeholders, vendors, and business partners as it relates to electronic data interchange and automated claims adjudication and processing.


Position Responsibilities:


• Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.

• Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.

• Provides first-level technical support to providers, users, and internal staff utilizing the In-house Provider Portal.

• Primary point of contact for provider portal registration including portal agreement documentation, execution, reconciliation, and retention.

• Assists CalOptima providers and their staff as well as internal business units in the adoption of electronic data transactions and automated data processes.

• Develops training materials and desktop procedures related to EDI processes.

• Serves as subject matter expert as it relates to EDI processing and data transfers.

• Creates and issues status reports as required by ad hoc business needs or on a preestablished frequency.

• Completes other projects and duties as assigned.


Possesses the Ability to:


• Communicate clearly and concisely, both verbally and in writing.

• Work collaboratively with internal and external stakeholders.

• Establish and maintain effective working relationships with CalOptima leadership and staff.

• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

• Identify issues and problems related to process failures due to data or logic inconsistencies.

• Develop solutions and prepare recommendations for claims or data-related issues within EDI processes.


Experience & Education:


• Bachelor's degree in Business Administration, Computer Science, or related field; and/or equivalent combination of education and work experience required.

• 2 years of experience in claims administration and/or technical support or customer support or help desk environment required.

• 1 year of experience working with Microsoft Structured Query Language (SQL) or equivalent required.


Knowledge of:


• Effective communication techniques and strategies to assist provider, vendors, business stakeholders, and internal users with web-based applications, EDI transactions and processing.

• Methods and techniques for organizing and implementing programs and process enhancements.

• Familiarity with web-based applications, data and process flows, EDI healthcare-related transactions, standards and codes sets.


Department(s): eBusiness

Reports to: Manager, Electronic Business

FLSA status: Non-Exempt

Salary Grade: E - $23.08 - $32.79 ($48,000 - $68,200)


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.


If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation 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. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.


Job Location: Orange, California


Position Type:


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Program Specialist (eBusiness)

Orange, CA
Full Time

Published on 08/24/2023

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