Claims Audit Lead - Medical Coding Quality

PacificSource Health Plans; Bend (OR); On-site; USD 65,000 - 111,000; Full time

Job summary

PacificSource Health Plans in Bend, Oregon is seeking an experienced Claims Audit Supervisor to lead the Claims Audit team across medical, dental, vision and other lines.

You will drive production and quality, coach staff, coordinate with Compliance, Grievance and Appeals, and support continuous process improvements using lean methods.

This role requires strong leadership, attention to detail, and a commitment to HIPAA privacy and accurate claim outcomes.

Qualifications

• Minimum 4 years of complex claims management experience with auditing, billing, recovery.
• At least 1 year of supervisory experience.
• High school diploma or equivalent.
• Advanced skills in medical terminology, CPT/ICD-10 coding.
• Proficient with Microsoft Word and Excel.

Responsibilities

• Provide supervision, coaching, training, and leadership to assigned staff. Ensure claims processing meets department and company standards for production and quality.
• Evaluate team member performance using reports and metrics to identify training needs and support departmental goals.
• Oversee the Fraud, Waste, and Abuse claim review process. Assist with complex claims and documentation to identify potential fraud in collaboration with the Compliance team.
• Support the team in delivering exceptional claims service across all lines (medical, dental, vision, self-funded, individual, COBRA, etc.), ensuring accurate benefit interpretation.
• Oversee and assist with review, research of medical claims, and determine coverage based on contract, provider status and claims processing guidelines. Investigate and settle claims issues as needed. Relay information for dispute resolution, including research and response for Appeals and Grievances, to appropriate departments and personnel. Claims to include Dental.
• Collaborate with Grievance and Appeals to determine appropriate claims outcomes based on policy, contracts, and applicable laws.

Skills

Leadership

Claims auditing

Supervisory experience

Training

Quality assurance

Communication

Education

High school diploma

Tools

Microsoft Word

Microsoft Excel

Job description

PacificSource Health Plans in Bend, Oregon is seeking an experienced Claims Audit Supervisor to lead the Claims Audit team across medical, dental, vision and other lines.

You will drive production and quality, coach staff, coordinate with Compliance, Grievance and Appeals, and support continuous process improvements using lean methods.

This role requires strong leadership, attention to detail, and a commitment to HIPAA privacy and accurate claim outcomes.