Pacific Medical Centers Claims Adjudicator in Seattle, Washington


Find what you’re looking for in your career, at PacMed as a Claims Adjudicator in Seattle, WA.

This is a full time opportunity and is eligible for full benefits!

We are seeking a Claims Adjudicator who will adjudicate claims submitted by outside purchased services for PMC’s enrolled capitated population and communicates those actions.The Adjudicator will adjust complex claims for advanced processing needs, as well as respond to Customer Service Requests and resolve problem claim situations.

In this position you will:

  • Adjust claim benefit payments on the GE Centricity 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.

  • Adjudicate Universal Billing (UB) and HCFA claims for assigned lines of business (one or two of: Commercial, Medicare, Healthy Options, Basic Health Plan, USFHP) Have experience with areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health and Encounters).

  • Adjudicate 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).

  • Research unclear and unusual claims. Determine the delegation status of claims and prepare claims for submission to appropriate entity.


Required qualifications for this position include:

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

  • A minimum of 2 years’ experience in Managed Care operations, including a minimum of one year claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting.

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

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

  • 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.

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

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

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

Preferred qualifications for this position include:

  • Experience with IDX healthcare software application.

  • Experience in CHAMPUS, Medicare and/or Medicaid benefits/programs.

  • An 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.

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 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.

Schedule: Full-time

Shift: Day

Job Category: Billing / Insurance

Location: Washington-Seattle

Req ID: 181387