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Pinnacle Claims Management · 14 hours ago

Plan Coder

United States

Full-time

Remote

Entry, Mid Level

$47K/yr - $66K/yr

2+ years exp

Western Growers Health is part of the Western Growers Family of Companies, providing employer-sponsored health benefit plans for the agriculture industry. The Plan Coder position involves in-depth coding of pharmacy and medical plans, ensuring compliance with summary plan descriptions and supporting the health insurance operations.

Employee BenefitsHealth CareInsurance

Responsibilities

Plan code new business and plan changes

Verify new and existing plans loaded on the company’s claim management system against the appropriate Summary Plan Description to determine the accuracy of present and future claims payments

Respond to work orders received from examiners to investigate plan issues and irregularities

Evaluate testing requests for all new plans prior to loading them into the production system

Keep a detailed log of open and completed work

Document resolutions to closed work orders

Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses

Create and document a minimum of one new Standard Operating Procedure (SOP) annually

Identify, initiate and implement at least one process improvement and/or innovation annually

Maintain detailed log of plans that are currently being coded and in the process of being loaded

Send confirmations to internal stakeholders when applicable plans have been loaded

Work with programmers to test claims and related system programs to verify impact within the Health Care Processing System (HCPS)

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

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

Qualification

Plan codingClaims auditingHealth benefits analysisMicrosoft OfficeEditing skillsProofreading skillsTactDiplomacyWriting skillsLeadershipInitiative

Required

Exceptional ability to interpret summary plan descriptions of employee medical, dental, pharmacy benefits

Strong ability to work efficiently and effectively in a multiple task, multi-project, and multi-demanding environment to meet expected goals, dates, and milestones

Excellent writing, editing, and proofreading skills to compose and edit correspondence, reports, emails, and other written materials

Superior ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts

Advanced skills in Microsoft Office applications, specifically word processing and spreadsheets

Demonstrated ability to analyze and comprehend complex issues, and personalities using independent judgment, leadership, tact, diplomacy, and initiative

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

Preferred

BS/BA degree in computer science, business or related field and a minimum of two years of experience as a pharmacy, medical, dental claims auditor and/or plan testing experience