Senior Claims Audit & Coding 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 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.