Medical Coding & Claims Quality Lead

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

Job summary

PacificSource Health Plans in Boise, Idaho, is seeking a Claims Audit supervisor to lead and develop the Claims Audit team. You will ensure production and quality, resolve adjudication issues, and collaborate with Grievance and Appeals to determine outcomes.

The role requires at least 4 years in complex claims management, with at least 1 year in supervision, and a high school diploma. You will coach staff, analyze performance metrics, oversee fraud review, and ensure compliance with HIPAA.

Qualifications

• Minimum of 4 years of complex claims management experience, including auditing, billing, research, and recovery.
• At least 1 year of supervisory experience required.
• Experience in self-funded claims administration preferred.
• High school diploma or equivalent required.

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.
• Oversee and assist with review, research of medical claims, and determine coverage based on contract, provider status and claims processing guidelines.

Skills

Leadership

Staff supervision

Claims auditing

Training & coaching

Communication

Education

High school diploma or equivalent

Tools

Microsoft Word

Excel

Job description

PacificSource Health Plans in Boise, Idaho, is seeking a Claims Audit supervisor to lead and develop the Claims Audit team. You will ensure production and quality, resolve adjudication issues, and collaborate with Grievance and Appeals to determine outcomes.

The role requires at least 4 years in complex claims management, with at least 1 year in supervision, and a high school diploma. You will coach staff, analyze performance metrics, oversee fraud review, and ensure compliance with HIPAA.