Lead Claims Specialist - USFHP

Are you a claims professional ready to step into a lead role where your expertise drives real results? As a Lead Claims Specialist supporting the US Family Health Plan (USFHP) at Pacific Medical Centers, you''ll be the go-to authority for adjudicating purchased services claims for our enrolled capitated population - resolving complex claim situations, managing advanced processing needs, responding to customer service requests with accuracy and efficiency, and applying your expertise in TRICARE reimbursement to ensure compliant, timely claims resolution for our military beneficiary population.

Providence caregivers are not simply valued - they're invaluable. Join our team at Pacmed Clinics DBA Pacific Medical Centers and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.

Required Qualifications:

• Bachelor''s Degree in a related field, or equivalent experience in Health Care Business Administration
• 4 years experience in Managed Care operations, including a minimum of 3 years claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting
• 1 year experience performing the core job at Pacific Medical Centers, or equivalent external experience in a lead capacity
• Experience with information systems supporting the administration of managed care products
• Experience with IDX healthcare software application
• Experience in CHAMPUS, Medicare and/or Medicaid benefits/programs required
• Experience with all areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health, Home Infusion, Kidney Dialysis Centers, Encounters)
• CRT experience

Preferred Qualifications:

• Microsoft Windows, Word, Excel, and Mail experience

Why Join Providence?

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our mission to advocate, educate and provide extraordinary care.

Accepting a new position at another facility that is part of the Providence family of organizations may change your current benefits. Changes in benefits, including paid time-off, happen for various reasons. These reasons can include changes of Legal Employer, FTE, Union, location, time-off plan policies, availability of health and welfare benefit plan offerings, and other various reasons.

At Providence, our strength lies in Our Promise of "Know me, care for me, ease my way." Working at our family of organizations means that regardless of your role, we'll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate''s placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits.

Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.