Senior Claims Specialist - USFHP

Adjudicates all 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. Assists in managing the workflow of assigned Line of Business.  Acts as primary department resource for at least one major area of expertise (EDI, Health Plan Repricing, Health Plus Repricing, or HPR).

Providence caregivers are not simply valued – they’re invaluable. Join our team at Pacmed Clinics DBA Pacific Medical Centers and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.

Required Qualifications:

• Bachelor's Degree In related field or Equivalent experience in Health Care Business Administration.
• 4 years of Managed Care operations, including a minimum of 3 years claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting.
• Information systems supporting the administration of managed care products.
• IDX healthcare software application.
• CHAMPUS, Medicare and/or Medicaid benefits/programs.
• All areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health, Home Infusion, Kidney Dialysis Centers, Encounters).
• CRT.

Preferred Qualifications: 

• Microsoft Windows, Word, Excel, and Mail.

Why Join Providence?

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security.  We take care of you, so you can focus on delivering our mission to advocate, educate and provide extraordinary care.