[Hiring] Lead Claims Specialist @Providence

Role Description

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.
• Design, plan, direct and implement claims training programs for the organization, including adaptations to changes in policies, procedures, and technologies.
• Familiar with applicable State and Federal claim payment and denial timeliness legislation.
• Familiar with Timeliness Compliance pursuant to State and Federal rules and regulations.
• Well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455).
• Responsible for ensuring customer (provider-vendor) satisfaction while maintaining integrity.
• Demonstrates a high level of integrity and innovative thinking, actively contributing 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.

Qualifications

• 5 years professional and facility claims processing experience

Benefits

• Comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching.
• Health care benefits (medical, dental, vision).
• Life insurance and disability insurance.
• Time off benefits (paid parental leave, vacations, holidays, health issues).
• Voluntary benefits and well-being resources.
• Additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Company Description

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.

• Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security.
• 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 foster an inclusive workplace where diversity is valued, and everyone is essential, heard, and respected.
• Together, our 120,000 caregivers serve in over 50 hospitals, over 1,000 clinics, and a full range of health and social services across multiple states.
• Providence Clinical Network (PCN) is a service line within Providence serving patients across seven states with quality, compassionate, coordinated care.