Claims Analyst II

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: Process professional medical claims pended for manual adjudication in assigned Workflow roles. Accurately interpret benefit and policy provisions applicable to fully-insured group/individuals and self-funded clients. Review claim to determine coverage based on contract, provider status, and claims processing guidelines. Develop and deliver one-on-one training to others using Lean training techniques. Provide back-up claim data entry assistance. Essential Responsibilities: Review and accurately process professional medical claims that pend for manual adjudication in assigned claims processing Workflow roles according to member’s plan benefits and department claims processing policies and procedures. Verify accuracy of data entry including patient information, procedure and diagnosis codes, amount(s) billed, and provider data. Review plan benefits and determine coverage based on contract and claims processing guidelines. Use ‘notes’ system to record pertinent information involving a claim or member. Review claims set-aside for further action and ensure they are released in a timely manner. Document issues that affect claims processing quality and advise team leader of claims processing concerns and/or problems. Follow HIPAA laws and regulations concerning confidentiality and security of protected health information. Develop training materials and deliver one-on-one training to other claims analysts using Lean training techniques as assigned. Provide assistance to other internal departments in responding to questions regarding claims processing. Supporting Responsibilities: Provide back-up assistance for medical and dental claims data entry as needed. Regularly attend team meetings and daily team Visual Board huddle. 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 or 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. Basic knowledge of Government Programs (Medicare/Medicaid) structure 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 live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business: 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 actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. We encourage creativity, innovation, and the pursuit of excellence. 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.