Operations Specialist II
Description
Western Growers Health─a part of Western Growers Family of Companies─provides employer-sponsored health benefit plans to meet the needs of those working for the agriculture industry. The unmatched benefit options provided by Western Growers Health stem from the core mission of Western Growers Association (est. 1926) to support the business interests of employers in the agriculture industry.
Our mission at Western Growers Health is to deliver value to employers by offering robust health plans that meet the needs of a diverse workforce. By working at Western Growers Health, you will join a dedicated team of employees who 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 Western Growers Health today!
Compensation: $45,091 - $63,617 with a rich benefits package that includes profit-sharing.
JOB DESCRIPTION SUMMARY
This position reports to the System Operations Manager, Key Accounts and serves as a critical operational resource responsible for adjudicating complex claims, analyzing claim payment accuracy, performing root cause analysis on claim deficiencies, and supporting leadership in continuous quality improvement. This role manages claims and financial workflows across the enterprise Flexible Spending Accounts (FSA), Health Reimbursement Account (HRA), and Health Savings Account (HAS) portfolios exclusively for WEX clients. Incumbent will support claims quality assurance, evaluate payment integrity programs, financial reporting, client account management, and operational process improvements. The incumbent will support leadership through proactive analysis of claims trends, development of corrective actions, and implementation of reporting solutions to ensure operational excellence.
Q U A L I F I C A T I O N S
- BA/BS degree in accounting, finance or business-related field preferred plus a minimum of three (3) to four(4) years of experience in healthcare claims adjudication, financial account maintenance, or claims operations in a Third-Party Administrator (TPA), health plan, or healthcare financial services environment, preferred.
- Strong understanding of medical, dental, vision, and reimbursement claims processing; familiarity with FSA/HRA/HSA administration.
- Skills to establish priorities, multi-task, work under pressure and deadlines, work independently with minimal supervision or in team environment.
- Intermediate knowledge of end-user office software i.e. calendaring, word-processing, spreadsheet and email and the ability to develop strong proficiency working with a proprietary Health Care system.
- Excellent written and oral communication skills, to include modern business communications, formatting professional letters, reports and phone etiquette.
- Customer service oriented.
- Ability to analyze and resolve technical problems and/or client inquiries as they arise.
- Knowledge of health insurance industry and standard health care eligibility provisions.
- Ability to work independently and collaboratively in a remote environment.
- Ability to work overtime as requested by management and based upon department needs and compliance.
- Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
- Home router with wired Ethernet (wireless connections and hotspots are not permitted).
- A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
- A functioning smoke detector, fire extinguisher, and first aid kit on site.
D U T I E S A N D R E S P O N S I B I L I T I E S
Claims Processing & Quality Assurance
- Adjudicate all claim types (medical, dental, vision, reimbursement) in accordance with Plan Documents, Standard Plan Design (SPD), and internal Standard Operation Procedures (SOP) in the company’s internal claims and financial processing system.
- Review and resolve claims requiring customer follow-up, benefit clarification, or cross-departmental collaboration.
- Evaluate payment integrity programs through data reporting, proactively identify anomalies, and recommend corrective actions.
- Assist with investigation and remediation of claim errors identified through quality control audits or leadership requests.
Financial Reporting & Account Maintenance
- Maintain/manage all Pinnacle Claims Management, Inc. (PCMI) contribution/premium reimbursements, FSA/HRA/HSA reimbursements.
- Manage the process of funding and releasing self-funded claims payments.
- Analyze and resolve claims-related account discrepancies, including the application of refunds, adjustments, and ledger maintenance Maintain FSA (Flexible Spending Account) HSA (Health Savings Account) HRA (Health Reimbursement Arrangement) program.
Process Management & Customer Service
- Verify/authorize refund for terminations and overpayments on all accounts.
- Participate in cross-functional initiatives to improve claims and financial processing efficiency.
- Identify process gaps or inefficiencies and recommend improvements to systems, workflows, or reporting tools.
- Process related written and verbal account inquiries to its conclusion in a timely manner to include research on as needed basis.
- Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
- Create and document Standard Operating Procedures (SOP’s).
- Identify, initiate and implement process improvements and/or innovation.
- Serve as a subject matter expert and escalation point for complex claim adjudication, financial inquiries, and operational process questions for WEX clients and Account Management team.
- Work collaboratively with internal teams (Eligibility, Customer Service, IT) to resolve account issues and support a high standard of client service.
- Partner with leadership to prepare and present operational updates and claim performance reports for internal and external stakeholders.
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 helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.
- Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
- Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
- Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
- All other duties as assigned.
P H Y S I C A L D E M A N D S / W O R K E N V I R O N M E N T
The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. 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 communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.