Lead Claims Specialist – TRICARE & USFHP Expert

PacMed Clinics; Renton (WA); On-site; USD 37,000 - 58,000; Full time

Job summary

PacMed Clinics is seeking a Lead Claims Specialist to drive adjudication of purchased services claims for our enrolled capitated population. You will resolve complex claims, oversee advanced processing, and respond to customer service requests with precision.

Leverage TRICARE reimbursement expertise to ensure compliant, timely resolution for military beneficiaries. Join a team focused on patient-centered care and operational excellence.

Qualifications

• Bachelor's degree or equivalent in health care administration or related field.
• 4 years in Managed Care operations with at least 3 years in claims processing.
• 1 year in lead capacity at Pacific Medical Centers or similar external experience.
• Experience with information systems for managed care administration.
• Experience with IDX healthcare software application.
• Experience with CHAMPUS, Medicare and/or Medicaid benefits/programs.
• Experience with COB, Adjustments, POS, Home Health, Home Infusion, Kidney Dialysis Center claims.
• CRT experience.

Responsibilities

• Adjudicate purchased services claims for enrolled capitated population.
• Resolve complex claim situations and manage advanced processing needs.
• Respond to customer service requests with accuracy and efficiency.
• Apply TRICARE reimbursement expertise to ensure compliant, timely claims resolution.

Skills

Claims processing

Leadership

Customer service

Healthcare administration

Education

Bachelor's Degree in Health Care Administration or related field

Tools

IDX healthcare software

Microsoft Word

Microsoft Excel

Job description

PacMed Clinics is seeking a Lead Claims Specialist to drive adjudication of purchased services claims for our enrolled capitated population. You will resolve complex claims, oversee advanced processing, and respond to customer service requests with precision.

Leverage TRICARE reimbursement expertise to ensure compliant, timely resolution for military beneficiaries. Join a team focused on patient-centered care and operational excellence.