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Pacific Medical Centers Claims Adjudicator - Uniformed Services Family Health Plan *Up to $2,000 Hiring Bonus* in Seattle, Washington

Description:

Find what you’re looking for in your career, at PacMed as a Claims Adjudicator (1.0 FTE, Day Shift) to work in Uniformed Services Family Health Plan in Seattle, WA .

$2K Sign On Bonus. $1,000 payout at the time of hire and $1,000 at the anniversary date of 12 months

Adjudicates 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.

In this position you will:

  • Adjusts claim benefit payment on the IDX computer system; including manual calculations of complex items and manual adjustment to the system as needed to correctly adjudicate claim benefit payment for plan benefits, enrollment contracts, reimbursement schedule, provider contracts, and referral authorization.

  • Adjudicates Universal Billing (UB) and HCFA claims for assigned lines of business (one or two of: Commercial, Medicare, Healthy Options, Basic Health Plan, USFHP)

  • Adjudicates claims in accordance with all legislative and regulatory compliance requirements including Medicare Regulations, Medicaid Regulations, Washington State Insurance Code, state legislative mandates, Health Care Financing Administration (HCFA) regulations, Office of the Insurance Commissioner (OIC) requirements, and contractual obligations with other entities (such as Health Plan contractual delegation agreements).

  • Researches unclear and unusual claims. Determine delegation status of claims and prepares claim for submission to appropriate entity.

  • Reviews IDX computer system for inconsistencies and applies accurate claim payment including contract fee schedules and discounts, health plan benefits, health plan links, medical group risk, delegation and fund pool agreements, provider and facility reimbursement including capitation, sub-capitation, case rates, global rates, percentage discounts, usual and customary fee schedules, RVUs and RBRVS schedules, APC grouping index, DRG grouping index, per diems and health plan schedules and networks according to contract terms.

Qualifications:

Required qualifications for this position include:

  • H.S. Diploma or GED or equivalent educ/experience

  • Two (2) years experience in Managed Care operations

  • One (1) year Claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting

  • Experience with areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health and Encounters)

  • Information systems supporting the administration of managed care products

Preferred qualifications for this position include:

  • IDX healthcare software application.

  • CHAMPUS, Medicare and/or Medicaid benefits/programs

About Us:

Our mission is to provide respectful, high-quality, patient-focused healthcare to each person and to the communities we serve.Quality and respect. These are the words Pacific Medical Centers (PacMed) employees live and work by. PacMedis a private, not-for-profit, primary and integrated multispecialty health care network with 11 outpatient clinics across the Puget Sound region and more than 150 primary and specialty care providers. Affiliated with the Providence Health & Services system, PacMed provides patient-focused health care —and even same-day appointments —to nearly 100,000 patients in King, Snohomish and Pierce counties. We provide immediate access to cutting-edge technology, first-class facilities and board-certified specialists, many of whom have been listed as among “Seattle’s Best Doctors.” Pacific Medical Centers, PacMed, and their Affiliates' (collectively “PacMed”) comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. PacMed does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit https://pacmed.jobs/benefits/

Our Mission

Our mission is to provide respectful, high-quality, patient-focused healthcare to each person and to the communities we serve.

About Us

Quality and respect. These are the words Pacific Medical Centers (PacMed) employees live and work by. PacMed is a private, not-for-profit, primary and integrated multispecialty health care network with 10 outpatient clinics across the Puget Sound region and more than 175 primary and specialty care providers. Affiliated with the Providence Health & Services system, PacMed provides patient-focused health care — and even same-day appointments — to patients in King, Snohomish and Pierce counties. We provide immediate access to cutting-edge technology, first-class facilities and board-certified specialists, many of whom have been listed as among “Seattle’s Best Doctors.”

Pacific Medical Centers, PacMed, and their Affiliates' (collectively “PacMed”) comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. PacMed does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Schedule: Full-time

Shift: Day

Job Category: Claims

Location: Washington-Seattle

Req ID: 306019

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