Senior Claims Specialist - USFHP

Hbcu Connect, Llc; Renton (WA); On-site; USD 35,000 - 55,000; Full time

Job summary

Providence PacMed is seeking an experienced adjudicator to manage claims for capitated populations and to resolve complex processing needs. The role involves responding to customer service requests and guiding workflow within a major line of business.

It also requires expertise in areas such as EDI, health plan repricing, or HPR. The position emphasizes teamwork, patient-centered care culture, and the opportunity to contribute to a national healthcare network.

Qualifications

• Bachelor's degree in related field or equivalent experience in health care 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.
• Knowledge of 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.

Responsibilities

• 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).

Skills

Managed Care operations

Claims processing

IDX healthcare software

CHAMPUS Medicare Medicaid knowledge

MSO/TPA/HMO experience

Education

Bachelor's degree or equivalent in health care administration

Tools

Microsoft Windows

Microsoft Word

Microsoft Excel

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 theyre 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.

Why Join Providence?

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.

About Providence

At Providence, our strength lies in Our Promise of Know me, care for me, ease my way. Working at our family of organizations means that regardless of your role, well walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

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.

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. Learn more at providence.jobs/benefits.

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.

About the Team

Pacific Medical Centers (PacMed) is a private, not-for-profit, primary and integrated multi-specialty health care network with outpatient clinics and primary and specialty care providers in King, Snohomish and Pierce counties. We combine decades of patient-centered care with cutting-edge technology, first-class facilities and board-certified providers.

Our strong team environment and respect for our peopleat all levels and from all backgroundsallow us to provide authentic care that achieves the highest-quality patient outcomes, backed by the strong network of resources and support through our affiliation with the Providence family, including local partners like Swedish Health Services.

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.

For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern.

Pay Range: $25.61 - $39.88

The amounts listed 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.