Perform random audits of processed claims and report on results to help identify training needs, and system or process issues. Review and research medical claims and determine coverage based on contract, provider status and claims processing guidelines. Accurately interpret benefit and policy provisions applicable to fully-insured group/individuals and self-funded clients. Responsible for identifying overpayments, preparing recovery requests, and performing follow-up tasks on outstanding overpayments. Provide customer service assistance to external customers regarding overpayment transactions.
Work Experience: Minimum of two years PacificSource claims adjudication experience, or equivalent health insurance claims experience, with the demonstrated ability to take on increasingly complex claims processing roles within Facets Workflow. Experience with account collections and handling difficult customers is helpful.
Education, Certificates, Licenses: Requires high school diploma or equivalent.
Knowledge: Thorough understanding of PacificSource products, plan designs, provider/network relationships and health insurance terminology. Research skills and ability to evaluate claims in order to enter and process accurately. Preferred computer skills include keyboarding and 10-key proficiency, basic Microsoft Word and Excel. Ability to prioritize work and perform under time constraints with minimal direct supervision. Ability to communicate effectively with all types of customers. Ability to develop Lean training materials and deliver claims training to others. A fundamental understanding of self-insured business is helpful.
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.
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.