Medi-Cal Claims Processing Specialist

Who We Are: 

Qualfon is a global provider of omnichannel customer experience and business support solutions. From call center support to lead generation to ecommerce fulfillment, we support our clients and their customers throughout the customer journey.  

Our mission is to help as many people as possible pursue their total vocation - as individuals and as members of society - by creating an ever-growing number of job opportunities as we strive to become the partner of choice for our clients. 

At Qualfon, you’ll find more than just a job, you’ll find a place to grow, develop your career, and be part of a supportive, purpose-driven team. 

What you'll do: 

Qualfon is seeking detail-oriented Medi-Cal Claims Processing Specialists to review and resolve suspended claims accurately and efficiently. The ideal candidate will have knowledge of healthcare billing, strong analytical skills, and the ability to apply policies and regulations while maintaining HIPAA compliance.

• Verify member eligibility, provider information, authorization requirements, and covered benefits.

• Review medical records, claim documentation, and billing information as needed.

• Identify and correct claim errors and make appropriate adjudication decisions.

• Resolve claim issues accurately within established deadlines and productivity standards.

• Apply Medi-Cal policies, regulations, and payment guidelines.

• Protect confidential information and maintain compliance with HIPAA requirements.

What you'll bring:

• Minimum of two (2) years of experience in Medicaid/Medi-Cal claims processing and adjudication.

• Knowledge of medical terminology and healthcare billing practices.

• Familiarity with CTP, HCPCS, and ICD-10 coding concepts.

• Strong attention to detail with the ability to ensure accurate, high-quality, and timely claims adjudication.

• Ability to interpret and apply policies, procedures, and regulatory requirements.

• Strong organizational, time-management, and prioritization skills.

• Ability to work efficiently in a fast-paced, production-driven environment.

• Ability to read, understand, and apply established policy guidelines.

• Proficiency in claims processing systems and Microsoft Office applications.

Work at Home Requirement:

• High-speed Internet via wired ethernet connection, no Wi-Fi, Satellite or Hot Spot
• Wired provider- No mobile broadband connections allowed
• Upload speed of 25 Mbps; Download speed of 50 Mbps
• The Internet service provider (ISP) must be highly stable with 1% or less packet loss
• Latency under 100ms
• Must have available cell phone or tablet with minimum system requirements of Android 8.0 and later or iOS14 or later and must install the Microsoft Authenticator (MFA) Application required by Qualfon IT.

Internet Reimbursement: Agents receive a $75.00 monthly stipend to help offset the cost of their home internet service while working remotely.

What We Offer: 

We lead by example to ensure our fantastic team members and supervisors embrace and live the Qualfon Mission to make each person's life better.

• Paid training
• All team members can further their education and earn a college degree through the Qualfon University scholarship program
• Team members have FREE access to personal and professional support through the Qualfon Care Coaches
• Last but not least, Qualfon is dedicated to ensuring all team members have Fun@Work!

EEO Statement 

QUALFON is an equal opportunity employer. QUALFON provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity, national origin, age, disability, genetic information (including testing and characteristics), marital status, ancestry, status as a covered veteran, uniformed servicemember status and any other characteristic protected under applicable federal, state or local law.