Senior Claims Specialist

Providence • Renton, WA

2d • Hybrid

About The Position

The Senior Claims Specialist adjudicates claims submitted by outside purchased services for the enrolled capitated population and communicates claim decisions. The role adjusts complex claims requiring advanced processing, responds to Customer Service Requests, and resolves problem claim situations. It also assists with managing the workflow of an assigned Line of Business and serves as the department’s primary resource for at least one major area of expertise: EDI, Health Plan Repricing, Health Plus Repricing, or HPR.

The position is with Pacmed Clinics DBA Pacific Medical Centers, part of Providence, and supports its patient-focused, whole-person care mission.

Requirements

• Bachelor’s degree in a related field, or equivalent experience in Health Care Business Administration.
• Four years of Managed Care operations experience, including at least three years of claims processing experience in a TPA, MSO, HMO, PHO, or large group practice setting.
• Experience with information systems supporting the administration of managed care products.
• Experience with the IDX healthcare software application.
• Knowledge of CHAMPUS, Medicare, and/or Medicaid benefits or programs.
• Experience with specialty claim processing areas including COB, Adjustments, Point of Service, Home Health, Home Infusion, Kidney Dialysis Centers, and Encounters.
• CRT.

Nice To Haves

• Microsoft Windows, Word, Excel, and Mail.

Responsibilities

• Adjudicate claims submitted by outside purchased services for the enrolled capitated population and communicate claim actions.
• Adjust complex claims requiring advanced processing.
• Respond to Customer Service Requests and resolve problem claim situations.
• Assist in managing the workflow of an assigned Line of Business.
• Act as the primary department resource for at least one major area of expertise: EDI, Health Plan Repricing, Health Plus Repricing, or HPR.

Benefits

• Competitive pay.
• Full medical, dental, and vision coverage from the first day.
• 401(k) plan with employer matching and a complementary retirement planner.
• Generous paid time off for vacation, sick days, and holidays.
• Tuition reimbursement and student loan forgiveness programs.
• Wellness and mental health assistance programs.
• Back-up child and elder care.
• Voluntary benefits, including pet, auto, and home insurance and commuter benefits.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior