Claims Specialist - USFHP

Job Description

Adjudicates 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.

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 :

• H.S. Diploma or GED or Equivalent experience in Health Care Business Administration
• 2 years In Managed Care operations
• 1 year 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

Preferred Qualifications :

• IDX healthcare software application
• CHAMPUS, Medicare and / or Medicaid benefits / programs

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.

About Us

At Providence, our strength lies in Our Promise of "Know me, care for me, ease my way." Working at our family of organizations means that regardless of your role, we'll walk alongside you in your career, supporting you so you can support others.

We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected.

Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington.

As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

The amounts listed 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.

Check out our benefits page for more information about our Benefits and Rewards.

About the Team

Providence Physician Enterprise (PE) is a service line within Providence serving patients across seven states with quality, compassionate, coordinated care.

Collectively, our medical groups and affiliate practices are the third largest group in the country with over 11,000 providers, 900 clinics and 30,000 caregivers.

• PE is comprised of Providence Medical Group in Alaska, Washington, Montana and Oregon; Swedish Medical Group in Washington's greater Puget Sound area, Pacific Medical Centers in western Washington;
• Kadlec in southeast Washington; Providence's St. John's Medical Foundation in Southern California; Providence Medical Institute in Southern California;
• Providence Facey Medical Foundation in Southern California; Providence Medical Foundation in Northern and Southern California;

and Covenant Medical Group and Covenant Health Partners in west Texas and eastern New Mexico.

Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.