What are the responsibilities and job description for the Provider Reimbursement Associate position at PacificSource Health Plans?
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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.
The Provider Reimbursement team supports Enterprise Cost-of-Care management processes and stakeholders including Provider Network, Facets Business Support, Facets Technical Support, Claims, Actuarial, Finance and Analytics departments in claims coding, hospital charge master and evaluation, reimbursement methodology research, and configuration of payment for all lines of business. The Provider Reimbursement Associate supports payment integrity processes for Commercial, Medicare and Medicaid.
Essential Responsibilities:
- Process and reconcile provider payments, in coordination with Finance, Health Services, Analytics, and other internal departments.
- Track payments made to external providers, including check runs.
- Track and research provider inquiries. In collaboration with other Provider Network staff, work directly with providers to clarify and resolve payment issues.
- Maintain provider fee schedules and payment methodologies.
- Maintain routine audits of provider rosters and support the payment process for the Patient-Centered Primary Care Home PMPM program.
- Audit provider contracts and claims payments.
- Analyze provider reimbursement and contracts.
- Develop and maintain documentation and train staff.
Supporting Responsibilities:
- Participate in department training and meetings as needed to become cross-trained and proficient in other areas of the department.
- 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.
- Perform other duties as assigned.
SUCCESS PROFILE
Work Experience: Minimum of 3 years’ experience in health insurance is required. Relevant experience in claims and continuous improvement preferred.
Education, Certificates, Licenses: High School diploma or equivalent required.
Knowledge: 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. Ability to critically review and interpret complex materials and make recommendations. Understanding of contractual language needed. Must be detail oriented, able to read financial statements, and understand basic accounting. Experience required in Microsoft Office Suite and Microsoft Teams. 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. Knowledge of reimbursement methodologies and experience using spreadsheets to develop reports required.
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, Listening (active), Organizational skills/Planning and Organization, Problem Solving, 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.
