Pacific Medical Centers Claims Adjudicator - Uniformed Services Family Health Plan in Seattle, Washington
Find what you’re looking for in your career at PacMed as a Claims Adjudicator with our Uniformed Services Family Health Plan in Seattle,WA.
We are seeking a Claims Adjudicator to adjudicate claims submitted by outside purchased services for PMC’s enrolled population and communicates those actions. He or she will adjust complex claims for advanced processing needs and will respond 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.
Required qualifications for this position include:
H.S. Diploma or GED OR equivalent educ/experience.
Two (2) years in Managed Care operations.
One (1) year of 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.
Knowledge of CPT, ICD9, HCPCS, RBRVS, ASA, and medical terminology.
Preferred qualifications for this position include:
IDX healthcare software application.
CHAMPUS, Medicare and/or Medicaid benefits/programs.
Pacific Medical Center :
Pacific Medical Center is an expanding network of outpatient clinics providing primary and specialty care to the greater Seattle area and employing more than 150 providers representing most medical specialties . Pacific Medical Centers is affiliated with Providence Health & Services, which operates 28 exceptional not-for-profit hospitals and more than 350 clinics across the West. With hundreds of physician and advanced practice provider opportunities in virtually all specialties at any given time, Pacific Medical Centers and Providence offer diverse locations, lifestyles and practice models. Find what you are looking for in your next practice opportunity with Pacific Medical Centers! Learn more at www.pacmed.org/providerjobs
We offer a full comprehensive range of benefits — see our website for details —
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. 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.
Job Category: Billing/Insurance
Req ID: 258083