PacificSource Health Plans

Claims Manager - Medicaid and Medicare Claims Processing Department

Job ID
Regular Full-Time
Hiring Pay Range
# of Openings


Position Overview: Responsible for all aspects of the operations for the Government (Medicaid and Medicare) Claims Department.  Establish, monitor, and continuously improve processes and supporting policies and procedures that ensure the timely and accurate processing of claims.  Lead multiple teams supervised by Team Leaders to achieve department goals and metrics.  Collaborate with other departments to meet customer needs and improve the overall operational efficiency within the company.  Manage relationships and performance of vendors utilized for claims processing.  Provide coaching and development for Team Leaders and others in the claims department.  Develop budgets and manage spending within established budgets.  Lead change and encourage innovation and process improvement.  Ensure PacificSource’s reputation as a provider of outstanding service by supporting the vision, mission, and values of the organization.


Essential Responsibilities:

  1. Accountable for the proper administration of the claims processing function. Develop a strong understanding of Facets claims module including claims workflow.  Manage department productivity.  Meet coding and payment accuracy standards.  Reduce claims turnaround time to meet industry best practice benchmarks and company goals.  Monitor performance against established department performance standards, goals, priorities, and budgets.  Develop necessary reports to help manage department.  Manage compliance submissions as necessary, such as prompt payment.
  2. Responsible for accurate claim processing and payment. Ensure that claims are processed in accordance with reimbursement guidelines. Develop and implement processes that ensure accurate claim processing. Responsible for maintenance of applicable Claims Policies and Procedures.
  3. Responsible for process improvement within claims department and working with other departments to improve interdepartmental processes impacting claims workflows and productivity. Utilize lean methodologies for continuous improvement. Utilize daily visual board huddles that monitor key performance indicators for the department and identify improvement opportunities. Work cross-functionally to improve auto-adjudication and eliminate the manual processing of claims where possible. Identify changes in Facets configuration, workflow, and security needed to improve claim processing.
  4. Manage Claims Department staff. Provide leadership to the Claims Department including communication on priorities, company strategy, and department goals. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports. Responsible for training, hiring, development, and performance management of Claims staff. Responsible for ensuring adequate cross-training so that multiple people can perform all tasks.
  5. Responsible for apprising other departments of internal and external claim related issues that may impact the organization and take appropriate action to incorporate changes into the day-to-day operations of the Claims Department. Improve processes to increase department efficiency. Assist with high-level resolution of non-routine customer inquiries and complaints for all customers.
  6. Serve on various company committees as required or needed. Document and report any pertinent communications back to team leaders and/or team members.
  7. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  8. Responsible for oversight, management, development, implementation, and communication of department programs.
  9. Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
  10. Manage vendors utilized for claims processing. Responsibilities including reviewing and modifying contracts, establishing performance expectations, conducting regular meetings with vendors to review performance, and periodically surveying market for alternative vendors.
  11. Coordinate business activities by maintaining collaborative partnerships with key departments.
  12. Actively participate as a key team member in manager/supervisor meetings.

  13. Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.

  14. Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.

Supporting Responsibilities:

  1. Actively participate in department or inter-departmental workgroups. Share information or issues with department leaders.
  2. Meet department and company performance and attendance expectations.

  3. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.

  4. Perform other duties as assigned.


Work Experience: Minimum five years health insurance operations or similar experience.  Medicare and Medicaid experience preferred. A minimum of two years of management experience required.


Education, Certificates, Licenses: Requires high school diploma or equivalent. Bachelor’s degree preferred. Advanced skills in medical terminology, CPT/ICD-9/10 coding is desired.


Knowledge: Effective and responsive leader. Thorough understanding of PacificSource products, plan designs, provider relationships and health insurance terminology. Basic working knowledge of applicable Federal and State rules and regulations. Understanding of claims processing system and operations. Consistently helpful, confident, and pleasant with all types of customers, both internal and external. Ability to clearly communicate with co-workers and takes proactive, as well as responsive, action to ensure good service. Ability to work under time pressures and deal with difficult situations. Advanced PC skills, including ability to type using a standard keyboard and operate a 10-key pad accurately, word-processing skills, and spreadsheet data management and software skills. Team player. Collaborates with others and helps to accomplish objectives.



Our Values

  • Building Trust
  • Building a Successful Team
  • Aligning Performance for Success
  • Building Partnerships
  • Customer Focus
  • Continuous Improvement
  • Decision Making
  • Facilitating Change
  • Leveraging Diversity
  • Driving for Results
  • 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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