Senior Managed Care Claims Specialist

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

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.