Position Overview: Review claims and information received via telephone or a medical service questionnaire for possible other party liability. Determine coverage based on contract, provider status, and claims processing guidelines and accurately process according to benefit and policy provisions applicable to fully-insured group/individuals and self-funded clients. Research, document, and follow up on all motor vehicle, on-the-job, on-the-premises, or other third party liability cases. Provide customer service assistance to members involved in third party cases. Responsible for accurate tracking of monies owed to PacificSource to ensure prompt reimbursement, as well as reporting savings for third party cases. When applicable, procure appropriate subrogation or loan agreements.
Work Experience: Minimum of one year PacificSource claims adjudication experience or equivalent work experience in a related health field.
Education, Certificates, Licenses: High school diploma or equivalent required.
Knowledge: Claims processing experience with thorough understanding of PacificSource products, plan designs, and health insurance terminology. Working knowledge of medical terminology, CPT and ICD-9 coding. Basic knowledge of third party claims administration is helpful. Ability to research, record and track pertinent information accurately. Ability to prioritize work under time pressures. Previous customer service experience handling difficult customers is helpful. Preferred computer skills include keyboarding and 10-key proficiency, basic Microsoft Word and Excel. Ability to develop Lean training materials and deliver claims training to others. Ability to collaborate and help others accomplish team objectives.
· Building Customer Loyalty
· Building Strategic Work Relationships
· Continuous Improvement
· Building Trust
· Work Standards
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
Physical Requirements: Must be able to remain in stationary position for extended periods of time while performing core job functions. Occasionally position self to maintain workspace including under the desk. Constantly operate a computer and other office productivity machinery such as calculator, copy machine and computer printer. Ability to read and comprehend both written and spoken English. Frequently communicate with employees and customers, must be able to exchange accurate information in these situations.
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.