Senior Claims Specialist - USFHP

Providence Health Plan Group; Renton (WA); On-site; USD 35,280 - 54,938; Full time

Benefits offered by this job

Health care benefits

401(k) Savings Plan

Paid time off

Job summary

Providence Health Plan Group in Renton, WA is seeking a Claims Processor to adjudicate claims for its capitated population. You'll be responsible for complex claims adjustments and act as a primary resource in specific areas like EDI and Health Plan Repricing.

Join us and contribute to a patient-focused team that values its caregivers. Enjoy generous benefits including medical, dental, vision, and a 401(k) plan with employer matching.

Qualifications

• 4 years of Managed Care operations experience.
• 3 years of claims processing experience in relevant settings.
• Familiarity with specialty claim processing.

Responsibilities

• Adjudicates claims for enrolled capitated population.
• Communicates actions taken on claims.
• Acts as a primary resource for specific expertise areas.

Skills

Managed Care operations

Claims processing

IDX healthcare software application

Knowledge of Medicare and Medicaid

Education

Bachelor's Degree in related field or Equivalent experience

Tools

Microsoft Windows

Microsoft Word

Microsoft Excel

Mail

Job description

Description

Adjudicates all claims submitted by outside purchased services for PMC's enrolled capitated population and communicates those actions. Adjusts complex claims for advanced processing needs. Responds to Customer Service Requests and resolves problem claim situations. Assists in managing the workflow of assigned Line of Business. Acts as primary department resource for at least one major area of expertise (EDI, Health Plan Repricing, Health Plus Repricing, or HPR).

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 related field or Equivalent experience in Health Care Business Administration.
• 4 years of Managed Care operations, including a minimum of 3 years claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting.
• Information systems supporting the administration of managed care products.
• IDX healthcare software application.
• CHAMPUS, Medicare and/or Medicaid benefits/programs.
• All areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health, Home Infusion, Kidney Dialysis Centers, Encounters).
• CRT.

Preferred Qualifications

• Microsoft Windows, Word, Excel, and Mail.

Benefits

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.

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.

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.

Compensation

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.

Equal Opportunity Employer

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.

Requisition ID: 442924
Company: Pacific Medical Jobs
Job Category: Claims
Job Function: Revenue Cycle
Job Schedule: Full time
Job Shift: Multiple shifts available
Career Track: Admin Support
Department: 3060 WA USFHP
Address: WA Renton 620 Naches Ave SW
Work Location: Blackriver Corporate Park-Renton
Workplace Type: On-site
Pay Range: $25.61 - $39.88