Implementation Auditor

Western Growers Assurance Trust; Irvine (CA); On-site; USD 85,000 - 120,000; Full time

Job summary

Western Growers Assurance Trust is seeking a QA/Testing Specialist to verify and test health plans (medical/dental/vision) loaded to the claim system, ensuring compliance with summary plan descriptions. You will work with programming and operations to validate claims and produce monthly issue reports, while documenting SOPs and driving process improvements.

The role requires strong analytical and writing skills, experience with plan testing, and proficient use of Microsoft Office, with attention

Qualifications

• BS/BA in Business or related field with 3–5 years of relevant experience in medical/dental claims auditing or plan testing.
• Exceptional ability to interpret summary plan descriptions of benefits and responsibilities.
• Excellent writing, editing, and proofreading skills for formal correspondence and reports.
• Strong analytical mindset with attention to detail and the capacity to manage multiple tasks.

Responsibilities

• Perform in-depth plan coding and testing of new and existing health plans.
• Verify loaded plans against Summary Plan Descriptions to ensure accurate claims payments.
• Test all new plans prior to production for medical, dental, and vision plans.
• Collaborate with programmers to test claims and related system programs for impact.
• Produce monthly reports on plan issues and identify process improvements.
• Create and maintain SOP documentation and participate in process innovation.

Skills

Plan testing

System testing

HIPAA compliance

SOP documentation

Technical writing

Analytical skills

Communication skills

Microsoft Office

Attention to detail

Education

BS/BA in Business or related field

3-5 years medical/dental claims auditor or plan testing experience

Tools

Microsoft Office

Claim management system

Job description

Job Description SummaryPosition reports to the Supervisor, Benefit Installation & Distribution and performs in-depth plan coding and testing of new and existing business accounts. This position will ensure that all new and existing health (medical/dental) insurance plans underwritten by the Western Growers Assurance Trust (WGAT) and those of Pinnacle, Inc. (PCMI) are in compliance with the respective employers’ summary plan descriptions.Duties And ResponsibilitiesTestingUsing close and comprehensive analyses, 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.Test all new plans prior to loading them into production (medical, dental and vision plans).Work with programmers to test claims and related system programs to verify impact within the HCPS.System analysis and testing of mass system updates.Plan coding of new business and plan changes for medical, dental, and vision plans.Communicate with other operational departments, as necessary, to ensure smooth integration of new plans for both WGAT and PCMI moving into production.ReportingProvide monthly reporting of all requested plan issues submitted from the Claims department.Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.Create and document Standard Operating Procedures (SOP).Identify, initiate and implement process improvements and/or innovation.OtherUtilize 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.Physical Demands/Work EnvironmentThe 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.QualificationsBS/BA degree in Business or related field and a minimum of three (3) to (5) five years of recent experience as a medical/dental claims auditor or plan testing experience, preferred.Exceptional understanding and ability to interpret summary plan descriptions of employee medical/dental benefits.Strong ability to work efficiently and effectively in a multiple task, multi-project, and multi-demandingenvironment to meet expected goals, dates, and milestones.Ability to anticipate problems, recommend solutions, and exercise best judgement.Excellent writing, editing, and proofreading skills to compose and edit correspondence, reports, emails, and other written materials.Proficient ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts.Previous experience with conducting research and presenting complex information.Excellent communication and interpersonal skills.Superior organization skills and high attention to detail.Ability to learn complex business processes and appropriately apply knowledge to make informed decisions.Advanced skills in Microsoft Office applications.Knowledge of medical terminology. Familiar with ICD10, CPT, HCPC, and CDT codes.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.