Claims Examiner II

Western Growers; Fresno (CA); Remote; USD 39,000 - 56,000; Full time

Job summary

An established industry player is seeking a Claims Examiner II to join their dedicated team. This remote position offers the chance to make a significant impact in the health care industry by ensuring accurate claims processing and providing excellent customer service. With a focus on quality and efficiency, you will review and analyze health care claims, resolve discrepancies, and contribute to process improvements. If you're passionate about making a difference and possess strong analytical skills, this role is your opportunity to thrive in a supportive environment. Join a forward-thinking organization that values its employees and offers a competitive compensation package!

Benefits

Profit Sharing

Health Benefits

Flexible Work Environment

Qualifications

• 5+ years of experience in health claims examination preferred.
• Ability to interpret Plan Documents for accurate adjudication.

Responsibilities

• Adjudicate medical, dental, and vision claims accurately.
• Research and resolve claims discrepancies and eligibility issues.

Skills

Medical Terminology

Claims Adjudication

Data Entry

Communication Skills

Problem Solving

Education

High School Diploma

Experience as Health Claims Examiner

Tools

Microsoft Office

UB-04 and HCFA 1500 Forms

Job description

Part of the Western Growers Family of Companies,Western Growers Assurance Trust (WGAT)was founded in 1957 to provide a solution to a need in the agricultural community — a need for employer-sponsored health benefit plans not previously available from commercial health insurance carriers. WGAT is now the largest provider of health benefits for the agriculture industry. The sponsoring organization of WGAT is Western Growers Association, created in 1926 to support the business interests of employers in the agriculture industry. WGAT’s headquarters is located in Irvine, California.

WGAT’s mission is to deliver value to agriculture-based employer groups by offering robust health plans that meet the needs of a diverse workforce. By working at WGAT, you will join a dedicated team of employees who truly 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 WGAT today!

Compensation: $39,208 - $55,972 with a rich benefits package that includes profit-sharing.This is a remote position and can reside anywhere in the U.S.

JOB DESCRIPTION SUMMARY

The Claims Examiner II reports to the Supervisor of Claims. Claims Examiner II is responsible for reviewing and processing medical, dental, vision and electronic claims in accordance with state, federal and health plan regulatory requirements, department guidelines, as well as meet established quality and production performance benchmarks to include research and review of applicable documentation. This position will thoroughly review, analyze, and research health care claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The Claims Examiner II will assist in resolving escalated issues from provider customer service, member services, health plan, and other internal customers

Qualifications

• High school education or equivalent with five (5) to seven (7) years of experience as a health claims examiner or comparable industry experience preferred.
• A minimum of two 2 years’ experience as a claim’s examiner for medical, dental and vision claims, coordination of benefits, Medicare, subrogation, and accident claims
• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination
• Excellent knowledge of medical terminology.Familiar with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
• Good verbal and written communication skills.
• Proficient in 10-key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.
• Ability to work under pressure and adapt to changing environment.
• Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.
• 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.

Duties And Responsibilities

Claims Processing & Quality Assurance

• Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), FSA, foreign claims, outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, and Medicare Secondary Payer (MSP) by calculating benefit due to approve or deny, based on SPD.
• Review reports and research pending claims to ensure timely adjudication within accepted corporate cycle times. Reports include, but are not limited to, daily and pending reports, weekly cumulative pend, and other special reports as received from customer.
• Analyze patient and medical records to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly.
• Examine claim files for accuracy and make necessary adjustments and corrections: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation, perform complete file reviews when appropriate.
• Review and release High dollar claim or other complex claims as directed by the Claims Management.
• Research through all vendor portals, including but not limited to Valenz, Occunet, Anthem

• Resolve benefit and eligibility issues that require detailed knowledge, support for customers within the claims processing, Company and ERISA guidelines. Process medium to high level claims adjustments, re-pricing, and corrections.
• Research, resolve and respond toall correspondence and internal and escalated communication (Ops Connect) related to electronic and paper claims as assigned.
• Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
• Meet and maintain individual and department productivity and quality standards.

Process Improvement & Innovation

• Perform regulatory operations research to support guideline development, provide accurate analysis, documentation, and recommendations for improvements.
• Work with other claims’ colleagues and external department staff to capture and update business needs to provide and implement solutions for the department and the organization.
• Identify, based on review and research of pend reports, and inform management of opportunities for quality improvement and best practices of claims operations through re-training or system modifications.
• Assess the current state of operational procedures within claims to propose improvements to existing process and procedures
• Bring inconsistencies and problems to the attention of management to improve processes for increase in productivity.
• Initiate and execute Work Instructions to enhance claim documentation.

Problem Solving, Judgement & Compliance

• Examine problem, set of data, or text and consider multiple sides of an issue, weigh consequences before making a final decision.
• Ensure compliance with all appropriate policies and practices, local, State, Federal regulations and requirements regarding claims and contract administration.
• Function as a subject matter expert (SME) when partnering with peers to document and analyze functional requirements, identify gaps and alternative approaches to resolve problems.
• Contribute to defining and documenting standards and periodically reviewing them to integrate appropriate industry standards.
• Alert supervisors to potential higher risk compliance issues
• Make timely and effective decisions based on available information
• Recognize issues, analyzes, solves problems, researches, identifies trends and determines actions needed to advance the decision-making process within a realistic timeframe. Follows up as necessary.
• Involve the appropriate people in defining, understanding the impact, and resolving problems.

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, being self-accountable, creating a positive impact, and being diligent in delivering results.
• Maintain internet speed of 40MB download and 10MB 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.
  

Physical Demands/Work Environment

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.