Claims Specialist

About This Role

This role involves adjudicating and adjusting complex claims from outside purchased services for Pacific Medical Centers' capitated population. The specialist will also respond to customer service requests and resolve problematic claim situations.

Responsibilities

• Adjudicate claims submitted by outside purchased services for PMC's enrolled capitated population
• Communicate actions taken on claims
• Adjust complex claims for advanced processing needs
• Respond to Customer Service Requests
• Resolve problem claim situations

Requirements

• H.S. Diploma or GED or equivalent experience in Health Care Business Administration
• 2 years in Managed Care operations
• 1 year of 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)
• Knowledge of information systems supporting the administration of managed care products

Qualifications

• H.S. Diploma or GED or equivalent experience in Health Care Business Administration.
• 2 years in Managed Care operations and 1 year of Claims processing experience

Nice to Have

• Experience with IDX healthcare software application
• Knowledge of CHAMPUS, Medicare and/or Medicaid benefits/programs

Skills

* Required skills

Benefits