Senior Claims Lead — TRICARE & Managed Care

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

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