Claims Representative I - PSA Job Opening

Claims Representative I - PSA

PacificSource Health Plans

• Springfield, Oregon
$28,000.00 - $39,000.00 a year
Category: Inside Sales Representative
Accurately interpret regulatory guidelines for claims processing. Review and research claims and determine coverage based on plan documents and claims processing guidelines. Adjudicate claims for payment or denial within PacificSource Administrators standards for quality and production.

Responsibilities

  • Accurately process claims by researching benefits and claims policy and procedures. Research includes, but is not limited to:
  • Reading and understanding all related account and claim notes
  • Comparing procedures to diagnostic codes
  • Determine eligibility based on service date and plan parameters
  • Accurately enter claims to prevent duplicate reimbursements or overpayments
  • Review claims for inconsistencies between billed and election amount
  • Adjudicating point of sale transactions

2. Verify accurate data entry including member information, plan year, coding, dollar amounts and if required, denial code.

3. Release claim for payment or denial when research is complete, and claim is accurately adjudicated.

4. Work in assigned claims processing queues and assist in other areas as needed.

5. Document pertinent information involving a claim or a member in the system.

6. Using established communication channels, notify appropriate internal personnel of claims processing concerns and/or problems and clearly document issues that affect other PSA departments.


Supporting Responsibilities:
  • Participate in departmental meetings, training, and takes advantage of opportunities to increase knowledge and skills.
  • Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  • Meet department and company performance and attendance expectations.
  • Perform other duties as assigned.

Qualifications

Work Experience: One year of administrative experience preferably in medical or health insurance industry. Claims adjudication experience preferred.

Education, Certificates, Licenses: Requires high school diploma or GED.

Knowledge: Requires the ability to make decisions quickly and logically. Knowledge of medical terminology and medical coding a plus. Is able to prioritize work and perform under time pressures. Advanced PC skills, ability to type using a standard keyboard and operate a 10-key pad accurately. Ability to be flexible and to readily adapt to change. Understand the importance of courtesy to internal and external customers.

Competencies
  • Adaptability
  • Building Customer Loyalty
  • Building Strategic Work Relationships
  • Building Trust
  • Continuous Improvement
  • Contributing to Team Success
  • Planning and Organizing
  • Work Standards
Our Values
  • We are committed to doing the right thing.
  • We are one team working toward a common goal.
  • We are each responsible for our customers’ experience.
  • 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 communities-internal and external.
  • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately less than 2% of the time.
Physical Requirements: Requires long periods of sitting and working on a computer. 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.