Lead Claims Specialist - USFHP
About The Position
Are you a claims professional ready to step into a lead role where your expertise drives real results? As a Lead Claims Specialist supporting the US Family Health Plan (USFHP) at Pacific Medical Centers, you'll be the go-to authority for adjudicating purchased services claims for our enrolled capitated population — resolving complex claim situations, managing advanced processing needs, responding to customer service requests with accuracy and efficiency, and applying your expertise in TRICARE reimbursement to ensure compliant, timely claims resolution for our military beneficiary population. Providence caregivers are not simply valued – they’re invaluable. Join our team at Pacmed Clinics DBA Pacific Medical Centers and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.
Requirements
- Bachelor's Degree in a related field, or equivalent experience in Health Care Business Administration
- 4 years experience in Managed Care operations, including a minimum of 3 years claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting
- 1 year experience performing the core job at Pacific Medical Centers, or equivalent external experience in a lead capacity
- Experience with information systems supporting the administration of managed care products
- Experience with IDX healthcare software application
- Experience in CHAMPUS, Medicare and/or Medicaid benefits/programs required
- Experience with all areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health, Home Infusion, Kidney Dialysis Centers, Encounters)
- CRT experience
Nice To Haves
- Microsoft Windows, Word, Excel, and Mail experience
Responsibilities
- Adjudicating purchased services claims for the enrolled capitated population.
- Resolving complex claim situations.
- Managing advanced processing needs.
- Responding to customer service requests with accuracy and efficiency.
- Applying expertise in TRICARE reimbursement for compliant, timely claims resolution.
Benefits
- Best-in-class benefits uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
