PacificSource Health Plans

Claims Analyst II - Medicaid

US-OR-Bend
Job ID
2017-323
Type
Regular Full-Time
Hiring Pay Range
$15.50 - $16.75
# of Openings
3
Status
Non-Exempt

Overview

Process Medicaid professional claims in a workflow role environment. Accurately interpret benefit and payment provisions applicable to Medicaid enrollees. Review and resolve claim edits using multiple systems, processes and procedures. Maintain production and quality standards.

Responsibilities

  1. Work in assigned workflow role to process Medicaid professional claims.
  2. Accurately interpret benefit and payment provisions applicable to Medicaid enrollees.
  3. Review and resolve claim and system edits using multiple systems, processes and procedures.
  4. Apply appropriate pricing guidelines and job aids for professional’s claims requiring manual pricing.
  5. Use ‘notes’ system to record pertinent information with attention to detail involving a claim or member.
  6. Work independently under time pressure, and maintain company compliance by resolving and processing claims within the timelines established by regulatory agencies and the plan, according to the processes established by the plan.
  7. Document and report issues that affect claims processing or accuracy to claims leadership team.
  8. Identify and report suspected instances of fraud, waste and abuse to claims leadership team.
  9. Provide support to other claims analysts as needed. 

Supporting Responsibilities:

  1. Provide back-up assistance for claims analyst I as needed.
  2. Regularly attend team meetings and daily team Visual Board huddle.
  3. Work collaboratively in an objective, professional, and diplomatic manner with all parties involved in a workgroup or project.
  4. Meet department and company performance and attendance expectations.
  5. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  6. Perform other duties as assigned

Qualifications

Work Experience:  One year of experience working for PacificSource, or one year of claims processing experience.

 

Education, Certificates, Licenses: High school diploma or equivalent required.

 

Knowledge: Basic-intermediate proficiency in Microsoft Office Applications including Word and Excel. Basic knowledge of medical terminology and medical coding preferred. Knowledge of claims, authorization, and provider network preferred. Basic knowledge of Government Programs (Medicare/Medicaid) structure preferred. Excellent time management, critical thinking and research skills preferred.

 

Competencies

Our Values

  • Adaptability
  • Building Customer Loyalty
  • Building Strategic Work Relationships
  • Building Trust
  • Continuous Improvement
  • Contributing to Team Success
  • Planning and Organizing
  • Work Standards
  • We are committed to doing the right thing.
  • We are one team working toward a common goal.
  • We are each responsible for our customers’ experience.
  • 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 communities-internal and external.
  • We encourage creativity, innovation, continuous improvement, 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 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. 

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