Claims Analyst II
PacificSource

Job Info

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Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

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.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Position Overview: Responsible for processing Commercial claims of moderate complexity applicable to plan enrollees.

Essential Responsibilities:

• Work in assigned workflow role to process Commercial claims.
• Accurately interpret benefit and payment provisions applicable to enrollees.
• Review and resolve claim and system edits using multiple systems, processes and procedures.
• Apply appropriate pricing guidelines and job aids for claims requiring manual pricing.
• Responsible for entering system Notes to record pertinent information involving a claim or member.
• Responsible for monitoring and working claims set aside to ensure claims are released in a timely manner.
• Pursue answers to questions needed to process claim.
• Route to appropriate workflow queues to resolve set up issues.
• Work independently under time pressure, and maintain company compliance by resolving and processing claims within the timelines established by regulatory agencies and the plan.
• Document and report issues that affect claims processing or accuracy to claims leadership team.
• Identify and report suspected instances of fraud, waste and abuse to claims leadership team.

Supporting Responsibilities:

• Provide back-up assistance for Claims Analyst I as needed.
• Regularly attend team meetings and daily team Visual Board huddle.
• Work collaboratively in an objective, professional, and diplomatic manner with all parties involved in a workgroup or project.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information Perform other duties as assigned.

Work Experience:

• One year of PacificSource work experience, one year work experience in a general office role required, or a combination of equitable work and education experience required.
• Experience in a health related field preferred.

Education, Certificates, Licenses: High school diploma or equivalent required.

Knowledge:

• Ability to develop a thorough understanding of PacificSource products, plan designs, provider/network relationships and health insurance terminology.
• Must have necessary research skills and the 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 accuracy and speed.
• Must be a team player willing to collaborate and help others accomplish team objectives.
• A fundamental understanding of self-insured business is helpful. Basic knowledge of medical terminology and medical coding preferred.
• Knowledge of claims, authorizations, and provider network preferred.
• Excellent Time Management, Critical Thinking and Research skills preferred.

Competencies

• Adaptability
• Building Customer Loyalty
• Building Strategic Work Relationships
• Building Trust
• Continuous Improvement
• Contributing to Team Success
• Planning and Organizing
• Work Standards

Environment:

• Work inside in a general office setting with ergonomically configured equipment.
• Travel is required approximately 5% of the time.

Our Values

• 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.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

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.

This job has expired.