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Western Growers · 3 months ago

Reinsurance Analyst

United States

Full-time

Remote

Entry, Mid Level

$62K/yr - $85K/yr

2+ years exp

Western Growers is a part of the Western Growers Family of Companies, providing health benefit plans for the agriculture industry. The Reinsurance Analyst will support various departments to provide claims services to reinsurance carriers, ensuring maximum reimbursement for excess loss medical claims.

FinanceService Industry

Responsibilities

Gather, organize, and review all necessary claim information required to submit excess loss claims (stop loss claims) to various individual Reinsurance Carriers to insure maximum reimbursement

Submit claims, following Carrier Guidelines, based on reports generated after each payment run

Respond to internal/external customer inquiries and requests within the department-established timeframe

Troubleshoot for potential departmental policy and procedure issues

Ensure claims processed within the MEWA, ERISA, and California Department of Insurance standards, as they apply

Support clients, carriers and brokers at every step involved in completion of the claim reimbursement process

Monitor large case management files with utilization review, eligibility unit and claims examiners

Answer inquires related to Advance Funding

Prepare and send required monthly specific and aggregate stop loss reports for brokers, carriers, and clients

Create special ad hoc report requests

Ensure timely responses to customer inquiries and requests for data information

Analyze claims data, diagnosis reports and utilization review data to identify potential high dollar claimants

Create potential high dollar report required as monthly distribution to Reinsurance Carriers

Prepare and provide last quarter reporting to Account Managers as they prepare for client renewal

Identify and notify Account Managers, clients, and brokers of priority claims at year end to insure maximum reimbursement

Identify potential ongoing high dollar claimants for disclosure at renewal

Monitor the reinsurance process to ensure timely filings occur and year-end process meets client needs

Monitor catastrophic health claims for PCMI & WGAT to eliminate the possibility of lost reimbursements

Analyze high dollar claims to ensure maximum and prompt reimbursement

Meet 'Scheduled Adherence' average monthly metrics

Meet 'Conformance' average monthly metrics

Monitor for prompt reimbursement receipt (goal 18 days) of reporting submission documents

Audit Carrier response to ensure accurate reimbursement and submit payment appeal if necessary

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, being self-accountable, creating a positive impact, and being diligent in delivering results

All other duties as assigned

Qualification

Medical claims auditingICD-9ICD-10 knowledgeCPT codingERISA claims processingClaims data analysisCommunication skillsOrganizational skillsProblem-solving skills

Required

High school education or equivalent and minimum of two (2) to five (5) years of experience as a medical/dental claims auditor/investigator and/or medical insurance account management/sales

Basic knowledge of word processing, spreadsheet, presentation media and end-user office software

Ability to work under pressure and adapt to a changing environment

Knowledge and experience of International Statistical Classification of Diseases and Related Health Problems (ICD-9, ICD-10), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS II & III), coordination of benefits, Medicare, Hospital claims, surgery claims, subrogation, and accident claims

Proficient with terminology comprehension

Good verbal and written communication skills

Working knowledge of Employee Retirement Income Security Act of 1974, (ERISA) claims processing/adjudication guidelines

Exceptional organizational, time management, critical thinking, and problem-solving skills

Knowledge of client specific, potential, and aggregate reporting under reinsurance a plus