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. Research and resolve grievance and appeals for the commercial line of business, utilizing a higher level of adjudicator expertise, clinical interpretation and decision making. Contribute to establishing and/or revising claims research policies and procedures and look for ways to improve processes. Assist with claims and processes requiring high-level knowledge of clinical data, billing/coding, system functions and claims procedures.Assist in identifying potentially fraudulent claims. Review claim scenarios for final determinations. Review claim documents (i.e., medical records, operative reports, and diagnostic studies) and prepare documentation for utilization reviews. Coordinate efforts to recover erroneous payments made due to processing errors, misrepresentative billing, fraud, or abuse Essential Responsibilities: Participate in Provider/Member Appeals process. Provide high-level guidance on claims/processes requiring a higher-level of research and analysis, including, but not limited to - initial clinical evaluations, request and review of medical records, coding assistance and research (CPT, HCPC, ICD-10), including unlisted procedures and changes in diagnosis and procedure codes. Advise on claims received through the Advanced Rebill queue and the Compliance queue, demonstrating a high-level understanding of medical documentation, billing/coding, compliance, and claims processing guidelines. Demonstrate a lead role in system upgrades, acting as the interdepartmental point of contact for testing/support. Create/review documentation and facilitate training on changes resulting from system upgrades. Perform audits for tracking and reporting. Create and maintain a tracking method to share with manager and team leads for training and learning progress. Analyze audit data to identify major issues/opportunities for retraining. Advise and assist other departments regarding billing/coding guidelines, medical records review, claims processing guidelines and other issues. Provide high-level claims-related education as necessary to Configuration Analysts, Provider Service Representatives, Sales Representatives, etc. Develop and maintain collaborative relationships to facilitate the accomplishment of work goals. Review claims received through the Advanced Rebill and Compliance queues. These claims require additional research, including, but not limited to the following: initial clinical evaluations, request and review of medical records, coding assistance and research- CPT and ICD-10, including unlisted procedures and changes in diagnosis and procedures, system editing review. Develop standards by which to measure progress and communicate progress with Claims teams and other departments. Develop and track project plans for large upcoming projects that affect multiple areas. Support quality improvement initiatives, both internal and across departments. Document issues that affect other PacificSource departments and advise appropriate internal personnel of claims processing concerns and/or problems. Use established communication channels to notify internal departments and personnel. Document issues that affect claims processing quality and advise team leader of claims processing or system configuration concerns and/or problems. Conduct fraud, waste, and abuse audits in accordance with compliance and audit work plan and prepare audit reports for management, legal counsel. Identify, investigate, and resolve billing and coding related inquiries and complaints from beneficiaries, members, regulatory agencies and internal and external customers through demand for refund of overpayments and education to providers. Lead and participate in special projects and committees as assigned. Collaborate with other areas on cross functional tasks. Occasional use of portable scanner, fax machine, copier, etc. Supporting Responsibilities: 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. Interact with business leaders and users, including external partners and customers as required. Maintain professional, service-oriented relationships. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum 4 years claims adjudication at a claims level III or comparable experience preferred. Advanced skills in medical terminology, CPT and ICD-10 coding, and clinical background. Education, Certificates, Licenses: Requires high school diploma or equivalent. Certified Professional Coder (CPC) preferred and obtained within 1 year. Knowledge: Thorough understanding of PacificSource products, plan designs, provider/network relationships, health insurance terminology and industry requirements. A fundamental understanding of self-insured business is helpful. Awareness of healthcare regulatory trends, including the OIG work plan and other healthcare compliance enforcement priorities. Intermediate understanding of healthcare reimbursement issues involved in facility, supplier, provider contracts. Understanding of audit procedures (e.g., data collection and sampling methodologies). Ability to interact appropriately with all levels of management, especially physicians. Excellent oral and written communication and interpersonal skills. Strong analytical and mathematical skills. Demonstrate organizational and problem-solving research skills, and ability to evaluate situations for appropriate resolution. Ability to judge severity of problems and the need to escalate to management or employ external services. Demonstrate ability to organize and prioritize work. Demonstrate the ability to work independently with minimal oversight. Ability to read and understand health benefit language, medical records from both professional and institutional sources. Ability to successfully perform other coding audits to validate correct coding, which includes, but isn’t limited to, CPT and HCPCs coding. Preferred computer skills include keyboarding and 10-key proficient, basic Microsoft Word and Excel. 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. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Group Problem Solving, Listening (active), Organizational skills/Planning and Organization, Teamwork 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. PacificSource is anything but a typical health insurance company. Founded in 1933, we’re an independent, not-for-profit organization that puts our members, and their communities first—across Idaho, Oregon, Montana, and Washington. It's our 1,900 employees who make it happen: promoting health equity and partnering with providers to deliver better access to optimal, affordable care. So yes, with PacificSource, you get to do great things. In our effort to put members first—more than 600,000 of them—initiative, commitment, and hard work are supported and rewarded with excellent benefits, competitive wages, and opportunities for personal growth and advancement. Benefits: Flexible telecommute policy, medical, vision, and dental insurance, incentive program, paid time off and holidays, 401(k) plan, volunteer opportunities, tuition reimbursement and training, life insurance, and options such as a flexible spending account. We love our common purpose. Empowerment, flexibility, and sharing success make for a great place to work. Here’s what else we feel good about: A mission with a real sense of shared values Competitive wages and outstanding benefits, including telecommuting Opportunities for learning development and career advancement Organizational leadership style rooted in servant and transformational leadership A commitment to support the communities we serve A belief in the importance of work-life balance April 16: Central Oregon Community College Job Fes, 10a-1p (2600 NW College Way, Bend, OR 97703) April 17: Oregon State Spring Career Fair, 11a-3p at Career Center (725 Southwest 26th Street, Corvallis OR 97331) April 18: University of Oregon Spring Career Fair, 12p-4p at the EMU Ballroom (1395 University St, Eugene OR 97403) April 24: Linn Benton Community College Career Fair, 10a-2p (6500 Pacific Blvd SW, Albany OR 97321) May 14: Idaho Business League, 10a-2p at Courtyard by Marriot (1789 S Eagle Road, Meridian ID) PacificSource is an equal opportunity employer and a company that loves helping people. We work with our employees to understand their goals, and provide training, individual development, and career advancement opportunities to help them achieve just that. In 2023 alone we had 407 internal promotions! Certified Age Friendly Employer, 2023 | Age Friendly Institute Top Workplace 2023 and 2022 for Idaho | Idaho Press Top Workplace 2023 and 2022 for Oregon and SW Washington | The Oregonian #4 Healthiest Employer of Oregon 2021 | Portland Business Journal Healthy Worksite 2021 | Design Coalition in Montana PacificSource is an equal opportunity employer. Click here to review our AAP Policy Statement. If you have questions about working at PacificSource or need help with your application, please email HRrecruiting@PacificSource.com.