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: Provides a wide range of support to Provider Network, Facets Business Support, Claims, Finance and Analytics in coding, reimbursement methodology research, loading and documentation for all lines of business. Responsible for all regular and off-schedule fee schedule preparation and documentation, including Federal Registers, CMS, DRGs, ASC, ASP, Lab, DMAP, ASA, Essentials RBRVS and PacificSource default fee schedules.
Research, initiate and audit updates of published fee schedules for commercial and government lines of business. Research requests from internal and external customers on establishing fee allowances as appropriate for otherwise undetermined allowables and present recommendations to the Director of Provider Network. Perform regular reconciliation and administration payment processes for facilities, IPAs, provider groups and panels, and coordinate payments with Finance. Collaborate with Analytics on analyses projects, including, but not limited to, COB, contract renewals and initial negotiations and reimbursement trends. Communicate updates and trends to internal stakeholders. Responsible for invoice preparation, documentation and audit of provider network fees and capitation payments, as specified in agreements with provider groups, IPAs, provider panels and capitated entities. Work with Compliance Audit and Reporting Specialists to ensure post-claims audits are accurate, timely and consistent with PacificSource policies and procedures. Educate and train staff in reimbursement methodologies, payment policies and contract compliance. Develop policies and procedures related to duties.
Work Experience: Four years' experience in a closely related health insurance area. Knowledge of reimbursement methodologies and experience using spreadsheets to develop reports required.
Education, Certificates, Licenses: High School Education required with Bachelor's degree in business, healthcare administration, finance or mathematics preferred.
Language skills: Excellent written and oral communication, including diplomacy skills for working with the medical professional community as well as the members enrolled in a PacificSource plan. Ability to effectively explain administrative and claims procedures to provider office staff of varying educational backgrounds and familiarity with insurance billing.
Mathematical Skills: Intermediate math skills required, including percentages, ratios, graphing and spreadsheet skills.
Knowledge: Ability to critically review and interpret complex materials and make recommendations. Understanding of contractual language needed. Excellent written/oral communication skills required. Must be detail oriented, able to read financial statements, and understand basic accounting. Experience required in Word, Excel, Access and Publisher. Must have demonstrated ability to work independently and as a member of a team. Ability to initiate and successfully conclude projects by specified timeframes with minimal supervision is required.
Building Customer Loyalty
Building Strategic Work Relationships
Contributing to Team Success
Planning and Organizing
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
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.
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.