Implementation Auditor (50487)

Western Growers; Irvine (CA); On-site; USD 65,000 - 90,000; Full time

Job summary

Western Growers in Irvine, CA is seeking a detail-oriented Claims Auditor/Plan Tester to ensure health plans comply with SPDs and that claims are processed accurately. The role focuses on in-depth plan coding and testing for WGAT and PCMI, with collaboration across Claims and IT to validate plan changes before production.

You will develop SOPs, drive process improvements, and maintain HIPAA-compliant workflows while handling confidential data.

Qualifications

• BS/BA degree in Business or related field; 3–5 years in medical/dental claims auditing preferred.
• Strong ability to interpret summary plan descriptions of employee medical/dental benefits.
• Ability to manage multiple tasks and meet deadlines in a dynamic environment.
• Excellent writing, editing, and proofreading skills for reports and correspondence.
• Proficient in Microsoft Office applications.
• Knowledge of medical terminology and coding (ICD10, CPT, HCPCS, CDT).

Responsibilities

• Verify plans on the claim management system against SPDs to determine accuracy of claims payments.
• Test all new medical, dental, and vision plans prior to production.
• Collaborate with programmers to test claims and related system programs.
• Perform system analysis and testing of mass system updates.
• Code new business and plan changes for medical, dental, and vision plans.
• Provide monthly reporting of plan issues from Claims.
• Identify inefficiencies and suggest improvements to reduce risk and cost.
• Create and document Standard Operating Procedures (SOP).
• Identify and implement process improvements and innovation.
• Maintain HIPAA-compliant workstation and protect confidential data.
• Maintain and service safety equipment on site.

Skills

Attention to detail

Analytical thinking

Communication skills

Microsoft Office proficiency

Education

BS/BA degree in Business or related field

Tools

ICD10, CPT, HCPCS, CDT codes

Job description

Job Description Summary

Position 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.

Job Description Summary

Position 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 Responsibilities

Testing

• Using 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.

Reporting

• Provide 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.

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 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 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.

Qualifications

Qualifications

• BS/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-demanding environment to meet expected goals, dates, and milestones.

environment 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.