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Senior Claims Specialist
Providence. Adjudicate all claims submitted by outside purchased services for PMC's enrolled capitated population and communicate those actions .
About the role
Key responsibilities & impact- Adjudicate all claims submitted by outside purchased services for PMC's enrolled capitated population and communicate those actions
- Adjust complex claims for advanced processing needs
- Respond to Customer Service Requests and resolve problem claim situations
- Assist in managing the workflow of the assigned Line of Business
- Act as the primary department resource for at least one major area of expertise: EDI, Health Plan Repricing, Health Plus Repricing, or HPR
Requirements
What you’ll need- Bachelor's Degree in related field, or equivalent experience in Health Care Business Administration
- 4 years Managed Care operations, including a minimum of 3 years claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting
- Knowledge of information systems supporting the administration of managed care products
- Experience with IDX healthcare software application
- Knowledge of CHAMPUS, Medicare and/or Medicaid benefits/programs
- Knowledge of all areas of specialty claim processing, including COB, Adjustments, Point of Service, Home Health, Home Infusion, Kidney Dialysis Centers and Encounters
- CRT
- Microsoft Windows, Word, Excel, and Mail (preferred)
Benefits
Comp & perks- Competitive pay
- Full medical, dental and vision coverage from your first day
- 401(k) plan with employer matching
- Complementary retirement planner
- Generous paid time off for vacation, sick days and holidays
- Tuition reimbursement
- Student loan forgiveness programs
- Wellness and mental health assistance programs
- Back-up child and elder care
- Voluntary pet, auto and home insurance
- Commuter benefits
- Life insurance
- Disability insurance
- Paid parental leave
- Well-being resources