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Pinnacle Claims Management · 2 days ago

Claims Auditor

United States

Full-time

Remote

Entry, Mid Level

$47K/yr - $66K/yr

1+ years exp

Western Growers Health is a part of the Western Growers Family of Companies, dedicated to providing employer-sponsored health benefit plans for the agriculture industry. The Claims Auditor will perform in-depth audits to ensure compliance of health benefit plans and support the claims department by identifying issues and providing recommendations for improvement.

Employee BenefitsHealth CareInsurance

Responsibilities

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

Identify and escalate 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

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 communicate claims status with reinsurance carrier

Work with AVP of Claims, Claims Manager and Reinsurance Analyst as required

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/Dental Claims AuditingCPTICD-10 KnowledgeSummary Plan DescriptionsEnd-user Software ProficiencyBusiness Math KnowledgeWritten CommunicationVerbal CommunicationSelf-starter

Required

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