Senior Claims Specialist - USFHP

Responsibilities 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). Qualifications Bachelor's Degree in a 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. Experience with information systems supporting the administration of managed care products. Experience with IDX healthcare software application. Knowledge of 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. Preferred Qualifications Proficiency in Microsoft Windows, Word, Excel, and Mail. Benefits Our benefits program includes retirement 401(k) savings plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, paid time off, and other voluntary benefits. Equal Employment Opportunity 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. #J-18808-Ljbffr Pacific Medical Centers