Claims Auditor I

Claims Irvine, California Fresno, California


Description

You spend more than half of your waking hours working. Make these precious, fleeting moments matter by working for an organization and a cause you can believe in. 

Western Growers exists for one reason only: to ensure the future viability of its members – the hard-working, salt of the earth farmers who grow the fruits, vegetables and tree nuts that feed our nation and nourish our bodies. But their way of life, their ability to pass their multi-generational farms and family legacies on to their children and grandchildren, is being jeopardized by a host of threats, many of them beyond their control. They face a growing litany of laws and regulations that make it increasingly difficult and expensive to do business. 

Our members depend on us to help them remain competitive and profitable in spite of these trying circumstances, which we do by fighting – heart and soul – for them every single day. We passionately advocate for them in the halls of Congress and on the steps of the state capitol. We actively facilitate the advancement of technology designed to help them become more efficient and less dependent on diminishing resources. We diligently provide health insurance to their farm workers, as well as other insurance solutions tailored to the unique business. We do all of this, and more, from a position of leadership in the agriculture industry, which requires a team of intelligent, inquisitive and innovative individuals sold out for our common purpose.

To learn more watch our Company Video!


Job Description Summary

This position reports to the Supervisor of Claims and Audit and performs in-depth audits to ensure existing health (medical/dental) benefit plans of Wester Growers Assurance Trust or Pinnacle Claims Management, Inc. clients are in compliance with the respective employers’ summary plan descriptions.

Qualifications

  • BS/BA degree preferred and a minimum of three years of recent experience as a medical/dental claims auditor.
  • Three years’ experience processing group health claims.
  • Knowledge of Current Procedural Terminology (CPT) and International Statistical classification of Diseases and Related Health Problems (ICD 11 & ICD-10 & ICD-9) and medical terminology.
  • Exceptional understanding and interpretation of summary plan descriptions of employee medical/dental benefits.
  • Good ability to interpret provider contracts.
  • Proven ability as a self-starter to manage timelines and commitments.
  • Proficient in end-user software, e.g. word-processing and spreadsheets.
  • Exceptional written and verbal communication skills.
  • Good knowledge of basic business math.

Duties And Responsibilities

Claims Auditing

  • Perform routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory and timelines standards, business policy, and contract terms.
  • Ensure appropriate coding and system configuration of claims with the ability to extract and audit exception audit reports.
  • Researches claim processing problems and errors to determine their origin and appropriate resolution.
  • Prepare reports and summarize observations and recommendations for management.
  • Participate in communication with management regarding trends in order to improve claims processing accuracy and documented business rules for incorporation into training programs, policies and procedures.
  • Performs special project audits and reviews as requested by other departments / regions
  • Maintains a minimum audit accuracy rate of 2%.

Claims Department Support

  • Identify and escalate issues related to instructional material that is inaccurate, unclear or contains gaps and provide recommendations for correction of this material.
  • Confers with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.
  • Participates in departmental error logs analytics and includes the findings in training preparations.
  • Provides technical support, training assistance, and expertise to claims staff or other department as determined through audit findings.

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.