Lead Claims Specialist - Claims Processing

Manage the claims internal audit functions, which includes audit process for adjudicated claims and encounters. Monitor check run process for accuracy.  Develop policies and procedures for periodic claims audits and ensure compliance with affiliated health plans, client groups, and administrative contractual agreements.  Designs, plans, directs and implements claims training programs for the organization, to include adaptations to changes in policies, procedures and technologies. Must be familiar with applicable State and Federal claim payment and denial timeliness legislation. Must be familiar with Timeliness Compliance pursuant to State and Federal rules and regulations.  Must be well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455). Responsible for ensuring customer (provider-vendor) satisfaction while maintaining the integrity. Demonstrates a high level of integrity and innovative thinking and actively contributes to the success of the Team. Supports, encourages and models attitudes, actions and behaviors that will make Providence the best in the industry in customer measured quality and responsiveness requirements. Serves as a liaison between contracted health plans, patients, hospitals and the Information Technology Dept.  Provides day-to-day assistance and training on Claims compliance matters to the Claims Examiners and Adjudication teams.

Providence caregivers are not simply valued – they’re invaluable. Join our team at Providence Medical Foundation 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:

• 5 years professional and facility claims processing 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 of caring for everyone, especially the most vulnerable in our communities.

Providence Clinical Network (PCN)  is a service line within Providence serving patients across seven states with quality, compassionate, coordinated care. Collectively, our medical groups and affiliate practices are the third largest group in the country with over 11,000 providers, 900 clinics and 30,000 caregivers.

PCN is comprised of Providence Medical Group in Alaska, Washington, Montana and Oregon; Swedish Medical Group in Washington’s greater Puget Sound area, Pacific Medical Centers in western Washington; Kadlec in southeast Washington; Providence’s St. John’s Medical Foundation in Southern California; Providence Medical Institute in Southern California; Providence Facey Medical Foundation in Southern California; Providence Medical Foundation in Northern and Southern California; and Covenant Medical Group and Covenant Health Partners in west Texas and eastern New Mexico.

Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.