Process professional medical claims pended for manual adjudication in assigned Workflow roles. Accurately interpret benefit
and policy provisions applicable to fully-insured group/individuals and self-funded clients. Review claim to determine coverage based on contract,
provider status, and claims processing guidelines. Develop and deliver one-on-one training to others using Lean training techniques. Provide back-up claim data entry assistance.
Review and accurately process professional medical claims that pend for manual adjudication in assigned claims processing Workflow roles according to member’s plan benefits and department claims processing policies and procedures.
Verify accuracy of data entry including patient information, procedure and diagnosis codes, amount(s) billed, and provider data.
Review plan benefits and determine coverage based on contract and claims processing guidelines.
Use ‘notes’ system to record pertinent information involving a claim or member.
Review claims set-aside for further action and ensure they are released in a timely manner.
Document issues that affect claims processing quality and advise team leader of claims processing concerns and/or problems.
Follow HIPAA laws and regulations concerning confidentiality and security of protected health information.
Develop training materials and deliver one-on-one training to other claims analysts using Lean training techniques as assigned.
Provide assistance to other internal departments in responding to questions regarding claims processing.
Provide back-up assistance for medical and dental claims data entry as needed.
Regularly attend team meetings and daily team Visual Board huddle.
Meet department and company performance and attendance expectations.
Perform other duties as assigned.
Work Experience: One year of PacificSource work experience or equivalent work experience in a related health field.
Education, Certificates, Licenses: High school diploma or equivalent required.
Knowledge: Ability to develop thorough understanding of PacificSource products, plan designs, provider/network relationships and health insurance terminology. Research skills and ability to evaluate claims in order to enter and process accurately. Preferred computer skills include keyboarding and 10-key proficiency, basic Microsoft Word and Excel. Ability to prioritize work and perform under time constraints with minimal direct supervision. Ability to develop Lean training materials and deliver claims training to others. Team player willing to collaborate and help others accomplish team objectives. A fundamental understanding of self-insured business is helpful.
Building Customer Loyalty
Building Strategic Work Relationships
Contributing to Team Success
Planning and Organizing
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 encourage creativity, innovation, and the pursuit of excellence.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
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.
PacificSource is an equal opportunity and affirmative action employer.
PacificSource Health Plans - 23 months ago
copy to clipboard
PacificSource Health Plans is anything but a typical health plan. We’re a growing, independent, not-for-profit organization with a...