Lead Claims Specialist - USFHP

Pacific Medical Centers Corp; Renton (WA); Hybrid; USD 37,000 - 58,000; Full time

Job summary

Pacific Medical Centers is seeking a Lead Claims Specialist to oversee adjudication of purchased services claims for the USFHP enrolled population. You will resolve complex claim issues, manage advanced processing, and respond to customer requests with precision.

The role requires a Bachelor’s in a related field or equivalent experience, 4 years in managed care operations with 3+ years in claims processing, and lead capacity experience. Knowledge of IDX and CHAMPUS/Medicare/Medicaid is preferred.

Qualifications

• Bachelor’s degree or equivalent in healthcare administration or related field.
• 4+ years in managed care operations with at least 3 years in claims processing in a TPA/MSO/HMO/PHO or large practice.
• 1 year in a lead capacity at Pacific Medical Centers or equivalent external experience.
• Experience with information systems supporting managed care products.
• Experience with IDX healthcare software.
• Experience with CHAMPUS, Medicare and/or Medicaid benefits/programs.
• Experience with all areas of specialty claim processing (COB, Adjustments, POS, Home Health, Home Infusion, Kidney Dialysis Centers, Encounters).
• CRT experience.

Responsibilities

• Lead adjudication of purchased services claims for USFHP enrolled 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.

Skills

Managed care operations

TRICARE reimbursement

Complex claims adjudication

Lead / supervisory experience

Information systems for managed care

Education

Bachelor’s Degree in Healthcare Administration

Tools

IDX healthcare software

Microsoft Windows

Excel

Job description

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.

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.

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.