PacificSource Health Plans

  • Provider Reimbursement Analyst I

    Job Location US-OR-Bend
    Job ID
    Regular Full-Time
    Hiring Pay Range
    $19.50-$24.00 per hour
    # of Openings
  • Overview

    Provides a wide range of support to Provider Network, Facets Business Support, Claims, Finance and Analytics in coding, reimbursement methodology research, loading and documentation for all lines of business. Responsible for all regular and off-schedule fee schedule preparation and documentation, including Federal Registers, CMS, DRGs, ASC, ASP, Lab, DMAP, ASA, Essentials RBRVS and PacificSource default fee schedules.


    Essential Responsibilities:

    1. Research, initiate and audit updates of published fee schedules for commercial and government lines of business.
    2. Research requests from internal and external customers on establishing fee allowances as appropriate for otherwise undetermined allowables and present recommendations to the Director of Provider Network.
    3. Perform regular reconciliation and administration payment processes for facilities, IPAs, provider groups and panels, and coordinate payments with Finance.
    4. Collaborate with Analytics on analyses projects, including, but not limited to, COB, contract renewals and initial negotiations and reimbursement trends.
    5. Communicate updates and trends to internal stakeholders.
    6. Responsible for invoice preparation, documentation and audit of provider network fees and capitation payments, as specified in agreements with provider groups, IPAs, provider panels and capitated entities.
    7. Work with Compliance Audit and Reporting Specialists to ensure post-claims audits are accurate, timely and consistent with PacificSource policies and procedures.
    8. Educate and train staff in reimbursement methodologies, payment policies and contract compliance.
    9. Develop policies and procedures related to duties.


    Supporting Responsibilities:

    1. Participate in department training and meetings as needed to become cross-trained and proficient in other areas of the department.
    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: Four years’ experience in a closely related health insurance area. Knowledge of reimbursement methodologies and experience using spreadsheets to develop reports required.


    Education, Certificates, Licenses: High School Education required with Bachelor’s degree in business, healthcare administration, finance or mathematics preferred.


    Language skills: Excellent written and oral communication, including diplomacy skills for working with the medical professional community as well as the members enrolled in a PacificSource plan. Ability to effectively explain administrative and claims procedures to provider office staff of varying educational backgrounds and familiarity with insurance billing.


    Mathematical Skills: Intermediate math skills required, including percentages, ratios, graphing and spreadsheet skills.


    Knowledge: Ability to critically review and interpret complex materials and make recommendations. Understanding of contractual language needed.  Excellent written/oral communication skills required.  Must be detail oriented, able to read financial statements, and understand basic accounting.  Experience required in Word, Excel, Access and Publisher.  Must have demonstrated ability to work independently and as a member of a team. Ability to initiate and successfully conclude projects by specified timeframes with minimal supervision is required.



    Our Values

    • Adaptability
    • Building Customer Loyalty
    • Building Strategic Work Relationships
    • Building Trust
    • Continuous Improvement
    • Work Standards 
    • 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 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.


    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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