Lead Claims Specialist - USFHP

Pacific Medical Centers Corp; Renton (WA); Hybride; USD 56 000 - 87 000; Plein temps

Résumé du poste

Pacific Medical Centers (PacMed) is seeking a Lead Claims Specialist to oversee adjudication of purchased services claims for enrolled capitated populations, applying TRICARE reimbursement rules to ensure accurate, timely resolutions.

You will lead complex claim scenarios, manage advanced processing needs, respond to member and provider inquiries with precision, and collaborate with the USFHP team to maintain compliant operations across our Washington network.

Qualifications

• Bachelor's degree in 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.
• Microsoft Windows, Word, Excel, and Mail experience.

Responsabilités

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

Connaissances

Managed Care operations

Claims processing

Lead capacity

TRICARE reimbursement

Customer service

Microsoft Windows

Excel

Word

Mail

Formation

Bachelor's in Health Care Admin

Outils

IDX healthcare software

Description du poste

Description

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.

Required Qualifications:

• 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

Preferred Qualifications:

• Microsoft Windows, Word, Excel, and Mail experience

Why Join Providence?

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our mission to advocate, educate and provide extraordinary care.

About Providence

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits.

Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

About the Team

Pacific Medical Centers (PacMed) is a private, not-for-profit, primary and integrated multi-specialty health care network with outpatient clinics and primary and specialty care providers in King, Snohomish and Pierce counties. We combine decades of patient-centered care with cutting-edge technology, first‑class facilities and board‑certified providers.

Our strong team environment and respect for our people—at all levels and from all backgrounds—allow us to provide authentic care that achieves the highest‑quality patient outcomes, backed by the strong network of resources and support through our affiliation with the Providence family, including local partners like Swedish Health Services.

Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.

For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern.

Requsition ID: 460401
Company: Pacific Medical Jobs
Job Category: Claims
Job Function: Revenue Cycle
Job Schedule: Full time
Job Shift: Day
Career Track: Admin Support
Department: 3060 WA USFHP
Address: WA Renton 620 Naches Ave SW
Work Location: Blackriver Corporate Park-Renton
Workplace Type: Hybrid
Pay Range: $26.90 - $41.89
The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.