Claims Auditor

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: $46,669.19 - $65,668.60 with a rich benefits package that includes profit-sharing.
This is a remote position and can reside anywhere in the U.S.

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

• BS/BA degree preferred and a minimum of one (1) to three (3) years of recent experience as a medical/dental claims auditor.
• Three (3) years’ experience processing group health claims preferred.
• Knowledge of Current Procedural Terminology (CPT) and International Statistical classification of Diseases and Related Health Problems (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.

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.
• Research 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.
• Perform special project audits and reviews as requested by other departments/regions.

Claims Department Support

• Identify and elevate issues related to instructional material that is inaccurate, unclear or contains gaps and provide recommendations for correction of this material.
• 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 department as determined through audit findings.
• Support and assist management team in updating department policies and guidelines.

Pinnacle Risk Management Services – Claims – PM6000

• Adjudicate specific stop loss claims received from Third Party Administrators in accordance with stop loss policy terms and the plan document. Process complex claims for physician, hospital, and specialty areas with high degree of accuracy and productivity.
• Process stop loss claim adjustments, refunds, and checks according to company policies and procedures, within established dollar authority.
• Respond and assist with claim documentation and reports as needed.
• Identify process improvement opportunities and works to implement corrective actions.
• Coordinate and…