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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 in 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 capitated population and communicate those actions. The Claims Adjudicator will adjust complex claims for advanced processing needs and will respond to Customer Service Requests and resolves problem claim situations.

This is a full time position and is eligible for full benefits.

In this position you will:

  • Assist the utilization review and case management nurse with management of referrals and monitoring or institutional patients.

  • Provide customer service to all managed care patients of Pacific Medical Clinics as well as provides member services activities for existing and new Medical Services Organization (MSO) business

  • Action initiates through the automatic call distribution system (ACD), written inquiries and direct member contact; activities include timely, accurate and thorough responses to telephone, written and direct member contact inquiries as well as explanation/verification of benefits, customer education, resolution for both internal and external complaints and patient advocacy.

  • Provide functions that include marketing USFHP enrollment, mailing and processing enrollment applications, processing enrollment transfers, verifying eligibility through the DEERS computer system; responsible for maintaining coordination and reconciliation with the government’s information systems including DEERS

  • Prepares yearly enrollment fees, quarterly billing for enrollment fees, receives and posts paid fees, sends out past due notices, collection of overdue fees, and responds to calls regarding status of enrollment fees.

  • Research and resolve eligibility issues, dis-enroll members who have lost eligibility, and notify enrollees of changes in enrollment.


Required qualifications for this position include:

  • High School Diploma, GED or equivalent experience in Health Care Business Administration.

  • Minimum of two (2) years of experience in Managed Care operations, including a minimum of one (1) year of claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting.

  • Understanding of financial/administrative/clinical business functions and the interfaces/relationships between applications in healthcare.

  • Understanding of healthcare delivery systems, healthcare insurance, managed care, third party administration, HMOs, preferred provider networks, delegation and risk products.

  • Understanding of provider reimbursement practices including capitation, sub-capitation, case rates, global rates, per diems, percentage discounts, usual and customary fee schedules, RVU and RBRVS-based fee schedules, purchased repriced network, and health plan specific schedules.

  • Experience with information systems supporting the administration of managed care products.

  • Knowledge of CPT, ICD9, HCPCS, RBRVS, ASA, DRG, and medical terminology.

  • Typing and 10-key skills (40 wpm and 100 spm) and CRT experience.

  • Must be able to provide proof of US Citizenship; required to obtain ADP 2 security status.

Preferred qualifications for this position include:

  • Understanding of the principles, theories, and practices of benefit design, plan inclusions and exclusions, healthcare administration rules and regulations, subrogation, third party liability, reinsurance, and coordination of benefits

  • Experience with IDX healthcare software application

  • Experience in 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 .

We offer a full comprehensive range of benefits — see our website for details —

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: Billing/Insurance

Location: Washington-Seattle

Req ID: 212457