Review, analyze and process complex hospital and medical claims. Research and resolve grievance and appeals which need a higher level of adjudicator expertise, clinical interpretation and decision making, for all lines of business. Contribute to establishing and/or revising claims research policies and procedures and look for ways to improve processes. Work with external vendor(s) contracted to do claims analytics. Will be required to participate in the Analytic claims work group as well as the FWA work group and may be called upon to participate on other standing or ad hoc workgroups.
Work Experience: Minimum five years claims adjudication at a claims level III or comparable experience. Advanced skills in medical terminology, CPT and ICD9/10 coding.
Education, Certificates, Licenses: Requires high school diploma or equivalent. Certified as a Medical Claims Coder and or Certified Medical Records Auditor.
Knowledge: Research skills and ability to evaluate situations for appropriate resolution. Ability to read and understand health contracts, benefit language, medical records from both professional and institutional sources.
Has a thorough understanding of PacificSource products, plan designs, provider relationships and health insurance terminology. Has a basic working knowledge of Oregon Insurance Division rules and regulations. Moderate/high clinical interpretation skills. Thorough understanding of claims processing system and operation. Experience using Microsoft Word/Excel. Advanced keyboard and ten-key skills. Ability to work under time constraints and to quickly understand new information. Team player willing to collaborate with others and help accomplish objectives. Meet or exceed PacificSource performance expectations.
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.