Medical Coding Quality Team Lead

PacificSource; Springfield (OR); On-site; USD 65,000 - 111,000; Full time

Benefits offered by this job

Flexible telecommute policy

Medical, vision, and dental insurance

401(k) plan

Paid time off and holidays

Job summary

PacificSource is seeking a Claims Audit Manager to lead the Claims Audit team, ensuring adherence to policy and workflow across lines of business. You will supervise production and quality, resolve adjudication issues, and collaborate with Grievance and Appeals to determine outcomes.

Strong leadership and auditing skills are essential. Responsibilities include hiring, coaching, training, and evaluating staff, overseeing fraud review, and maintaining accurate documentation.

Qualifications

• Minimum of 4 years of complex claims management experience, including auditing, billing, research, and recovery, with supervisory experience.
• Experience in self-funded claims administration preferred.

Responsibilities

• Provide supervision, coaching, training, and leadership to assigned staff.
• Ensure claims processing meets department and company standards for production and quality.
• Oversee the Fraud, Waste, and Abuse claim review process.
• Assist with complex claims and documentation to identify potential fraud in collaboration with Compliance.
• Oversee and support the Claims Refunds team with adjusting claims for refunds and related reporting.
• Monitor outstanding refunds and develop processes to collect.

Skills

Leadership

Collaboration

Communication

Critical Thinking

Decision Making

Influencing

Active Listening

Organizational Skills

Education

High school diploma or equivalent

Tools

Microsoft Word

Excel

Job description

PacificSource Claim Audit Manager

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

Supervise and provide leadership to the Claims Audit team, ensuring adherence to company policies, procedures, and workflows across lines of business. Manage claims production and quality to meet or exceed company standards. Resolve adjudication issues, including additional payments and recoveries. Collaborate with Grievance and Appeals to research and determine appropriate claims outcomes. Responsible for hiring, training, coaching, and evaluating team performance. Demonstrate effective leadership by fostering individual growth, team collaboration, innovation, and commitment to organizational goals.

Essential 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. Support the team in delivering exceptional claims service across all lines (medical, dental, vision, self‑funded, individual, COBRA, etc.), ensuring accurate benefit interpretation. Oversee and assist with review, research of medical claims, and determine coverage based on contract, provider status and claims processing guidelines. Investigate and settle claims issues as needed. Relay information for dispute resolution, including research and response for Appeals and Grievances, to appropriate departments and personnel. Claims to include Dental. Communicate business process and procedural changes promptly to team members. Collaborate with the Training Coordinator on initial and ongoing education for staff. Oversee and assist responses to inquiries via mail or email, ensuring quality service and preparing reports or correspondence as needed. Participate in interoffice committees and share relevant updates with the team. Engage in Claims leadership peer group to promote cross‑team communication, collaboration, and process efficiency with results in consistent, quality claims processing outcomes. Evaluate stop‑loss contracts to ensure proper administration and prevent aggregate violations. Maintain open communication with Account Managers, agents, and carriers regarding stop‑loss status. Respond to inquiries regarding stop‑loss accounting and administration. Create manual reporting for internal and external recipients. Create manual Specific and Aggregate stop‑loss reporting, accounting for changes made based on claims analysis. Produce manual reporting to account for claims applying to overlapping contracts, claims applying to an aggregating‑specific deductible or contracts split between a current and prior group number or third‑party administrator. Document and escalate claims processing or system configuration issues to the Claims Manager. Provide expert‑level education and support to other departments on billing/coding, medical records review, and claims processing. Collaborate with Grievance and Appeals to determine appropriate claims outcomes based on policy, contracts, and applicable laws. Oversee and support the Claims Refunds team with adjusting claims for refunds, sending refund letters and follow‑up, sending to PRS for collection, posting refunds, balancing daily deposit and month end report. Monitor outstanding refunds and develop processes to collect. Maintain collaborative partnerships with key departments to coordinate business activities. Assist with hiring, staff development, performance reviews, corrective actions, and terminations. Conduct regular one‑on‑ones and evaluations. Assist with process improvement and work with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. Actively participate as a key team member in department meetings. Actively participate in department meetings and strategic/internal committees to share information and represent company values.

Supporting Responsibilities

Actively participate in department or inter‑departmental workgroups. Share information or issues with department leaders. Regularly attend team meetings and daily team Visual Board huddle. Meet department and company performance and attendance expectations. Perform other duties as assigned.

Success Profile

• Work Experience: Minimum of 4 years of complex claims management experience, including auditing, billing, research, and recovery, with demonstrated leadership capabilities. At least 1 year of supervisory experience required.
• Experience in self‑funded claims administration preferred.

Education, Certificates, Licenses

Requires high school diploma or equivalent. Knowledge: Thorough understanding of PacificSource products, plan designs, provider relationships and health insurance terminology or the ability to learn. Basic working knowledge of Insurance Division rules and regulations per state.

Accountable for the quality and accuracy of all documents, files and records used to substantiate stoploss cases.

• Advanced PC skills including Microsoft Word and Excel.
• Ability to type using a standard keyboard, operate 10‑key pad accurately, multi‑line telephone system, and fax machine.
• Research skills and ability to evaluate claims in order to audit accurately.
• Advanced skills in medical terminology, CPT / ICD‑10 coding.
• Thorough understanding of PacificSource products, plan designs, provider relationships, and health insurance terminology, or ability to learn quickly.
• Basic working knowledge of Insurance Division rules and regulations.
• Accountable for the accuracy of documentation supporting stop‑loss cases.
• Advanced PC skills, including Microsoft Word and Excel.
• Proficient in keyboarding, 10‑key, multi‑line phone systems, and fax machines.
• Strong research and evaluation skills for accurate claims auditing.
• Advanced knowledge of medical terminology and CPT/ICD‑10 coding.

Competencies

Building Trust, Building a Successful Team, Aligning Performance for Success, Building Customer Loyalty, Building Strategic Work Relationships, Continuous Improvement, Decision Making, Facilitating Change, Leveraging Diversity, Driving for Results.

Environment

Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Skills

Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and Organization.

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range: $65,296.83-$111,004.62

Our Values

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities‑internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements

Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer

This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT‑WILL at all times.

PacificSource Overview

PacificSource is anything but a typical health insurance company. Founded in 1933, we’re an independent, not‑for‑profit organization that puts our members, and their communities first—across Idaho, Oregon, Montana, and Washington. It's our employees who make it happen: promoting health equity and partnering with providers to deliver better access to optimal, affordable care. So yes, with PacificSource, you get to do great things. In our effort to put members first—more than 525,000 of them—initiative, commitment, and hard work are supported and rewarded with excellent benefits, competitive wages, and opportunities for personal growth and advancement.

Benefits

• Flexible telecommute policy
• Medical, vision, and dental insurance
• Incentive program
• Paid time off and holidays
• 401(k) plan
• Volunteer opportunities
• Tuition reimbursement and training
• Life insurance
• Options such as a flexible spending account

Additional Achievements

Top Workplace 2026, 2025 and 2024 USA | USA Today 2025 Healthcare Top Workplaces | Energage Top Workplaces # 6 Healthiest Employer of Oregon 2025 | Portland Business Journal Top Workplace 2024, 2023 and 2022 for Oregon and SW Washington | The Oregonian Top Workplace 2025, 2024, 2023 and 2022 for the Treasure Valley | Idaho Press Certified Age Friendly Employer, 2023 | Age Friendly Institute PacificSource is an equal opportunity employer.