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 (1.0 FTE, Day Shift) in Uniformed Services Family Health Plan at Seattle, WA.
We are seeking a Claims Adjudicator to adjudicate claims submitted by outside purchased services for PMC’s enrolled capitated 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.
Brings any breech of compliance-related issue to the attention of department management.
Runs and reviews report on claims activity. Reviews and re-adjudicates pending claims.
Corresponds with vendors and members in writing regarding claims payments.
Documents Policies and Procedures for use in training, to ensure accurate claims processing, and to communicate policies to other departments within Pacific Medical Centers.
Updates management when error trends indicate that there is a need for additional training.
Required qualifications for this position include:
High School Diploma, GED or equivalent experience in Health Care Business Administration.
Two (2) plus years’ 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.
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.
Must possess an understanding of financial/administrative/clinical business functions and the interfaces/relationships between applications in healthcare.
Must possess an understanding of healthcare delivery systems, healthcare insurance, managed care, third party administration, HMOs, preferred provider networks, delegation and risk products.
Must possess an 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.
Preferred qualifications for this position include:
Experience with IDX healthcare software application
Experience in CHAMPUS, Medicare and/or Medicaid benefits/programs
PacificMedical 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: 235088