Lead Claims Specialist - USFHP

Providence; Renton (WA); On-site; USD 90,000 - 120,000; Full time

Job summary

Providence’s Pacific Medical Centers USFHP team seeks a Lead Claims Specialist to adjudicate purchased services for enrolled capitated populations. You will resolve complex claims, manage advanced processing needs, and respond to customer inquiries with accuracy, leveraging TRICARE reimbursement rules for compliant, timely resolution.

The role emphasizes leadership in a claims-focused environment within the Providence family of organizations, supporting patient-centered, whole-person care in the

Qualifications

• Bachelor's degree in a related field or equivalent experience in health care business administration
• 4 years in managed care operations with at least 3 years in claims processing in a large organization
• 1 year in a lead capacity at Pacific Medical Centers or equivalent
• Experience with information systems supporting management of managed care products
• Experience with IDX healthcare software application
• Experience with CHAMPUS, Medicare and/or Medicaid benefits/programs
• Experience in specialty claim processing areas (COB, Adjustments, POS, Home Health, Home Infusion, Kidney Dialysis, Encounters)
• CRT experience

Responsibilities

• Lead adjudication of 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 knowledge to ensure compliant, timely claims resolution for military beneficiaries

Skills

Claims processing

Managed Care operations

IDX healthcare software

TRICARE/CHAMPUS knowledge

COB/Adjustments/POS

CRT experience

Education

Bachelor's degree or equivalent in Health Care Admin

Tools

IDX healthcare software

Windows/Office tools (Word, Excel, Mail)

Job 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.

Accepting a new position at another facility that is part of the Providence family of organizations may change your current benefits. Changes in benefits, including paid time-off, happen for various reasons. These reasons can include changes of Legal Employer, FTE, Union, location, time-off plan policies, availability of health and welfare benefit plan offerings, and other various reasons.