Claims Examiner

Claims Irvine, California


Description

Western Growers Assurance Trust (WGAT) was founded in 1957 to provide a solution to a need in the agricultural community — a need for employer-sponsored health benefit plans not previously available from commercial health insurance carriers. WGAT is now the largest provider of health benefits for the agriculture industry. The sponsoring organization of WGAT is Western Growers Association, created in 1926 to support the business interests of employers in the agriculture industry. WGAT’s headquarters is located in Irvine, California.

WGAT’s mission is to deliver value to agriculture-based employer groups by offering robust health plans that meet the needs of a diverse workforce. By working at WGAT, you will join a dedicated team of employees who truly care about offering quality health benefits and excellent customer service to plan participants. If you want to start making a difference working in the health care industry, then apply to WGAT today!

JOB DESCRIPTION SUMMARY

Position reports to Supervisor, Claims in a production environment.  Claims Examiner I will review and process medical, dental, vision and electronic claims within the established turn-around time and quality standards of the department. Position may also process Flexible Spending Account (FSA) and Health Insurance Payment Demand (HIPD) claims.

Qualifications

  • High school education or equivalent and/or one year of experience as a claims examiner processing group health indemnity claim, group medical or related fields.
  • One year experience of International Classification of Diseases (ICD) 9 and 10, coordination of benefits, Medicare, surgery claims, subrogation, and accident claims.
  • Proficient with medical coding and terminology.
  • Good verbal and written communication skills.
  • Proficient in ten key data entry.
  • Ability to work under pressure and adapt to changing environment
  • Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.
  • Proficient in Microsoft Office (Word, Excel, Outlook).
  • Reliability and a strong work ethic are a must.
  • Ability to work overtime as needed.

Duties And Responsibilities

Claims Processing

  • Examine and process medical, dental, vision claims including: physician claims, Medicaid reclamation, HIPD, FSA, other re-pricing claims, emergency room, outpatient lab and x-ray, accident and Third Party Liability (TPL) claims, Medicare Secondary Payer (MSP) and surgery claims.
  • Resolve pended claims within Employee Retirement Income Security Act (ERISA) guidelines
  • Research and complete all correspondence related to all electronic and paper claims assigned

Quality Results

  • Meet department standards for both production and quality
  • Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
  • Respond to internal/external customer inquiries and requests within the established timeframe

 

Other

  • Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.
  • Other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand, walk and sit. The employee is frequently required to use hands to finger, handle, or feel objects, tools, or controls and reach with hands and arms. The noise level in the work environment is usually moderate.