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PacificSource Health Plans Claims Audit Specialist - Government in Bend, Oregon


Perform random audits of processed claims and report results to help identify training needs, and system or process issues. Review and research medical claims and determine coverage based on contract, provider status and claims processing guidelines. Accurately interpret benefit and policy provisions applicable to Medicare and Medicaid programs.

Application Timelines:

  • Accepting applications through September 30, 2019

  • Conducting interviews from October 1 - October 15

  • Anticipated start in November 2019


  • Perform random and problem-focused audit of claims by researching benefits, claim edits, claim policies and procedures and compare against processed claim. Provide immediate feedback on claims with errors, notifying original claims analyst, and team leader.

  • Accurately resolve or reprocess claims to correct setup and/or system errors identified through multiple channels according to the instructions provided for the project.

  • Work assigned reports to monitor and/or correct claims for specific processing reasons. May also assist in processing other specialty claims as workload or auditing requires.

  • Document issues that affect other PacificSource departments and advise appropriate internal personnel of claims processing concerns and/or problems. Use established communication channels to notify internal departments and personnel.

  • Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.

  • Provide customer service assistance to internal and external customers to answer questions and resolve refund issues.

  • Document issues that affect claims processing quality and advise team leader of claims processing or system configuration concerns and/or problems.

Supporting Responsibilities:

  • Actively participates in department or inter-departmental workgroups. Shares information or issues with department leaders.

  • Regularly attend team meetings and daily team Visual Board huddle.

  • 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.


Work Experience:Minimum of two years PacificSource claims adjudication experience, with the demonstrated ability to take on increasingly complex claims processing roles within Facets Workflow.

Education, Certificates, Licenses:Requires high school diploma or equivalent.

Knowledge:Thorough understanding of PacificSource Medicare and Medicaid products, plan designs, provider/network relationships and health insurance terminology. Research skills and ability to evaluate claims in order to enter and process accurately. Preferred computer skills include keyboarding and 10-key proficiency, basic Microsoft Word and Excel. Ability to prioritize work and perform under time constraints with minimal direct supervision. Ability to communicate effectively with all types of customers. Ability to develop Lean training materials and deliver claims training to others. A fundamental understanding of self-insured business is helpful.


Our Values

  • Adaptability

  • Building Customer Loyalty

  • Building Strategic Work Relationships

  • Building Trust

  • Continuous Improvement

  • Contributing to Team Success

  • Planning and Organizing

  • Work Standards

  • We are committed to doing the right thing.

  • We are one team working toward a common goal.

  • We are each responsible for our customers’ experience.

  • 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 communities-internal and external.

  • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.

Environment:Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

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.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

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.

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, national origin, sex, sexual orientation, gender identity or age.

Job ID2019-356

TypeRegular Full-Time

of Openings5