Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion:  PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

Accurately interpret regulatory guidelines for claims processing. Review and research claims and determine coverage based on plan documents and claims processing guidelines. Adjudicate claims for payment or denial within PacificSource Administrators standards for quality and production.

Essential Responsibilities:

Accurately process claims by researching benefits and claims policy and procedureReading and understanding all related account and claim notes Comparing procedures to diagnostic codesDetermine eligibility based on service date and plan parametersAccurately enter claims to prevent duplicate reimbursements or overpaymentsReview claims for inconsistencies between billed and election amountAdjudicating point of sale transactionsVerify accurate data entry including member information, plan year, coding, dollar amounts and if required, denial code. Release claim for payment or denial when research is complete, and claim is accurately adjudicated. Work in assigned claims processing queues and assist in other areas as needed.Document pertinent information involving a claim or a member in the system. Using established communication channels, notify appropriate internal personnel of claims processing concerns and/or problems and clearly document issues that affect other PSA departments.

Supporting Responsibilities:

Participate in departmental meetings, training, and takes advantage of opportunities to increase knowledge and skills.Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.Meet department and company performance and attendance expectations.Perform other duties as assigned.

Work Experience:

One year of administrative experience preferably in medical or health insurance industry. Claims adjudication experience preferred.

Education, Certificates, Licenses:

Requires high school diploma or GED.

Knowledge:

Requires the ability to make decisions quickly and logically.

Knowledge of medical terminology and medical coding a plus.

Is able to prioritize work and perform under time pressures.

Advanced PC skills, ability to type using a standard keyboard and operate a 10-key pad accurately.

Ability to be flexible and to readily adapt to change.

Understand the importance of courtesy to internal and external customers.

Competencies:

Building Customer Loyalty

Building Strategic Work Relationships

Contributing to Team Success

Planning and Organizing

Continuous Improvement

Adaptability

Building Trust

Work Standards

Environment:

Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately less than 2% of the time.

Skills:

Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

We are committed to doing the right thing.We are one team working toward a common goal.We are each responsible for customer service.We practice open communication at all levels of the company to foster individual, team and company growth.We actively participate in efforts to improve our many communities-internally and externally.We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.