Job Description

Job Opportunity At PacificSource

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Research, document, and follow up on motor vehicle, on-the-job, on-the-premises, or other third party liability cases. Act as Subject Matter Expert (SME) in regards to knowledge of applicable laws and insurance regulations. Review claims and information received via telephone or a medical service questionnaire for possible other party liability. Determine coverage based on contract, provider status, and claims processing guidelines and accurately process according to benefit and policy provisions applicable to fully-insured group/individuals and self-funded clients. Provide customer service assistance to members involved in third party cases. Responsible for accurate tracking of monies owed to PacificSource to ensure prompt reimbursement, as well as reporting savings for third party cases. When applicable, procure appropriate subrogation or loan agreements.

Job Description

Essential Responsibilities:

• Investigate claims that are possible third party routed to Third Party team via Facets Workflow. Determine a course of action based on information received from claims that are potentially related to a third party injury.
• Review and accurately process medical claims that pend for manual adjudication in assigned Third Party claims processing Workflow roles according to member's plan benefits and department claims processing policies and procedures.
• Assist with requesting accident information and documenting returned medical service questionnaires as needed.
• Provide customer service for third party case inquiries from external customers (members, providers, attorneys and other carriers), as well as internal departments. Log all third party case inquiry phone calls using Facets Call Tracking screen.
• Research, verify coverage third party carriers and document third party case information in the case screen with clear, concise, and up-to-date information using standard format and abbreviations. Enter general notes for adjudicators with specific processing instructions involving third party cases.
• Generate medical bill summary reports for members, lawyers, and other carriers to assure timely and accurate recovery of dollars paid by PacificSource.
• Follow assigned cases through to closure to ensure PacificSource has been reimbursed monies owed. Act as PacificSource liaison to the attorney representing the insured. Establish settlements to PacificSource with attorney, conferring with legal counsel on contested settlements. Negotiate settlements up to, but not to exceed, the limits set forth in the Third Party Settlement Procedure.
• Determine third party settlement savings and enter data into case savings program, which is used to generate quarterly savings reports for company performance measures.
• Prepare third party correspondence for imaging; set up tasks; maintain third party e-mail queue within time frames documented in Third Party procedure. Assist with policy and procedure development as needed.
• Prepare, send, and record Right of Recovery letters and Notice letters. Provide appropriate follow-up, including reviewing the member file for related claims.

Supporting Responsibilities:

• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Regularly attend team meetings and daily team Visual Board huddle.
• Meet department and company performance and attendance expectations.
• Perform other duties as assigned.

Success Profile:

Work Experience: One year work experience in a general office role required, or a combination of equitable work and education experience required. Health related experience preferred.

Education, Certificates, Licenses: High school diploma or equivalent required.

Knowledge: Claims processing experience with thorough understanding of PacificSource products, plan designs, and health insurance terminology. Working knowledge of medical terminology, CPT and ICD-10 coding. Basic knowledge of third party claims administration is helpful. Ability to research, record and track pertinent information accurately. Ability to prioritize work under time pressures. Previous customer service experience handling difficult customers is helpful. Preferred computer skills include keyboarding and 10-key proficiency, basic Microsoft Word and Excel. Ability to develop Lean training materials and deliver claims training to others. Ability to collaborate and help others accomplish team objectives.

Competencies:

• Building Customer Loyalty
• Building Strategic Work Relationships
• Contributing to Team Success
• Planning and Organizing
• Continuous Improvement
• Adaptability
• Building Trust
• 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, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Our Values:

• 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.

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