PacificSource Health Plans

  • Third Party Recovery Representative II

    Job Location US-OR-Eugene
    Job ID
    Regular Full-Time
    Hiring Pay Range
    # of Openings
  • Overview

    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.  


    Essential Responsibilities:

    1. Investigate claims that are possible third party routed to Third Party team via Facets Workflow. Determine a course of action based on information received from claims that are potentially related to a third party injury.
    2. Review and accurately process medical claims that pend for manual adjudication in assigned Third Party claims processing Workflow roles according to member’s plan benefits and department claims processing policies and procedures.
    3. Assist with requesting accident information and documenting returned medical service questionnaires as needed.
    4. Provide customer service for third party case inquiries from external customers (members, providers, attorneys and other carriers), as well as internal departments. Log all third party case inquiry phone calls using Facets Call Tracking screen.
    5. Research, verify coverage third party carriers and document third party case information in the case screen with clear, concise and up-to-date information using standard format and abbreviations. Enter general notes for adjudicators with specific processing instructions involving third party cases.
    6. Generate medical bill summary reports for members, lawyers, and other carriers to assure timely and accurate recovery of dollars paid by PacificSource.
    7. Follow assigned cases through to closure to ensure PacificSource has been reimbursed monies owed. Act as PacificSource liaison to the attorney representing the insured. Establish settlements to PacificSource with attorney, conferring with legal counsel on contested settlements. Negotiate settlements up to, but not to exceed, the limits set forth in the Third Party Settlement Procedure.
    8. Determine third party settlement savings and enter data into case savings program, which is used to generate quarterly savings reports for company performance measures.
    9. Prepare third party correspondence for imaging; set up tasks; maintain third party e-mail queue within time frames documented in Third Party procedure. Assist with policy and procedure development as needed.
    10. Prepare, send, and record Right of Recovery letters and Notice letters. Provide appropriate follow-up, including reviewing the member file for related claims.


    Supporting Responsibilities:

    1. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    2. Regularly attend team meetings and daily team Visual Board huddle.
    3. Meet department and company performance and attendance expectations.
    4. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    5. Perform other duties as assigned.


    Work Experience:  Minimum of one year PacificSource claims adjudication experience or equivalent work experience in a related health field required.


    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.  



    Our Values

    ·         Building Customer Loyalty

    ·         Building Strategic Work Relationships

    • Contributing to Team Success
    • Planning and Organizing

    ·         Continuous Improvement

    ·         Adaptability

    ·         Building Trust

    ·         Work Standards



    • We are committed to doing the right thing.
    • We are one team working toward a common goal.
    • We are each responsible for customer service.
    • 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 many communities-internally and externally.
    • We encourage creativity, innovation, 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: 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.





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