Claims Auditor II

Claims Irvine, California Fresno, California


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 inthe 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!

To learn more watch our Company Video!

Job Description Summary

This position reports to the Supervisor of Claims, Audit and performs in-depth audits to ensure existing health (medical/dental/vision) benefit plans of Western Growers Assurance Trust or Pinnacle Claims Management, Inc. clients are in compliance with the respective employers’ summary plan descriptions. In addition, this position will assist with claims training, review of error logs, and support to the examiners and audit staff.


  • BS/BA degree preferred and a minimum of five years of recent experience as a medical/dental/vision claims auditor and five 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/vision benefits.
  • Exceptional ability to interpret provider contracts, plan documents and respond to questions.
  • 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 to 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.
  • Research claim processing problems and errors to determine their origin and appropriate resolution.
  • Prepare reports and summarize observations and recommendations for management.
  • Communicate with management regarding trends in order to improve claims processing accuracy.
  • Document business rules for incorporation into training programs, policies and procedures.
  • Communicate requested claim details to specific clientele.
  • Perform special project audits and reviews as requested by other departments/regions.
  • Lead large dollar claim workflow for the audit team by providing training for level 1 auditors.
  • Provide process improvements recommendations to management and lead the large dollar committee meeting.
  • Maintain 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. Revise and communicate corrections of this material to staff.
  • Confer with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.
  • Participate in departmental error logs analytics and includes the findings in training preparations.
  • Provide technical support, training assistance, and expertise to claims staff or other departments as determined through audit findings.
  • Participate in claims staff performance improvement plans by providing additional auditing and/or basic coaching as needed.
  • Assist Auditor III in providing subject matter support for new hire training classes.


  • 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.
  • All 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.