Lead Claims Specialist - USFHP

About the role

As a Lead Claims Specialist supporting the US Family Health Plan (USFHP) at Pacific Medical Centers, you'll be the go-to authority for adjudicating purchased services claims for our enrolled capitated population. You will resolve complex claim situations, manage advanced processing needs, respond to customer service requests with accuracy and efficiency, and apply your expertise in TRICARE reimbursement to ensure compliant, timely claims resolution for our military beneficiary population.

Responsibilities

• Adjudicate purchased services claims for a capitated population
• Resolve complex claim situations and manage advanced processing needs
• Respond to customer service requests with accuracy and efficiency
• Apply TRICARE reimbursement expertise to ensure compliant, timely claims resolution
• Perform core lead duties in claims processing, including COB, adjustments, point of service, home health, home infusion, kidney dialysis centers, and encounters

Requirements

• Bachelor's Degree in a related field, or equivalent experience in Health Care Business Administration
• 4 years experience in Managed Care operations, including a minimum of 3 years claims processing experience in a TPA, MSO, HMO, PHO, or large group practice setting
• 1 year experience performing the core job at Pacific Medical Centers, or equivalent external experience in a lead capacity
• Experience with information systems supporting the administration of managed care products
• Experience with IDX healthcare software application
• Experience in CHAMPUS, Medicare, and/or Medicaid benefits/programs
• Experience with all areas of specialty claim processing (COB, adjustments, point of service, home health, home infusion, kidney dialysis centers, encounters)
• CRT experience

Preferred Qualifications

• Microsoft Windows, Word, Excel, and Mail experience

About the Team

Pacific Medical Centers (PacMed) is a private, not-for-profit, primary and integrated multi-specialty health care network with outpatient clinics and primary and specialty care providers in King, Snohomish, and Pierce counties. We combine decades of patient-centered care with cutting-edge technology, first-class facilities, and board-certified providers. Our strong team environment and respect for our people—at all levels and from all backgrounds—allow us to provide authentic care that achieves the highest-quality patient outcomes, backed by the strong network of resources and support through our affiliation with the Providence family, including local partners like Swedish Health Services.

Benefits

Providence offers a comprehensive benefits package including:

• A retirement 401(k) Savings Plan with employer matching
• Health care benefits (medical, dental, vision)
• Life insurance and disability insurance
• Time off benefits (paid parental leave, vacations, holidays, health issues)
• Voluntary benefits
• Well-being resources

Pay

The pay range for this position is $26.90 - $41.89 per hour. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Schedule

Full time, Day shift. This position is hybrid.