Reinsurance Analyst

Western Growers; Irvine (CA); Presencial; USD 60 000 - 90 000; Tempo integral

Resumo da oferta

Western Growers in Irvine, CA is seeking a Claims Auditor to support multiple departments in providing claims services to reinsurance carriers for excess loss medical claims through the Company's Trust and Employer Groups under TPA.

The role acts as subject matter expert in reviewing supporting documentation, client interactions, and reinsurance reporting, ensuring compliance with MEWA, ERISA, and California Department of Insurance standards.

Qualificações

• High school education or equivalent and 2–5 years of claims auditing experience.
• Knowledge of ICD-9/ICD-10, CPT, HCPCS II & III, COB, Medicare, subrogation, and ERISA guidelines.
• Strong verbal and written communication; able to work under pressure and adapt to a changing environment.
• Experience with client reporting and reinsurance reporting is a plus.

Responsabilidades

• Submit excess loss claims to reinsurance carriers following guidelines and after payment runs.
• Prepare monthly stop loss reports for brokers, carriers, and clients.
• Respond to internal/external inquiries within established timeframes.
• Analyze claims data and utilization review data to identify high-dollar claimants.
• Ensure compliance with MEWA, ERISA, and California Department of Insurance standards.

Conhecimentos

Attention to detail

Analytical thinking

Communication skills

Time management

Ability to work under pressure

Client service orientation

Formação académica

High School Diploma or equivalent

2–5 years medical/dental claims auditing experience

Ferramentas

MS Office

Descrição da oferta de emprego

Job Description Summary

This position reports to the Manager of Claims in a production environment and is responsible for supporting the various departments, within the company, to provide claims services to reinsurance carriers in order to obtain reimburse for excess loss medical claims on behalf of the Company’s Trust and Employer Groups associated under Third Party Administrator (TPA). This position is also the subject matter expert for the team in reviewing supporting documentation, client, and reinsurance reporting.

Job Description Summary

This position reports to the Manager of Claims in a production environment and is responsible for supporting the various departments, within the company, to provide claims services to reinsurance carriers in order to obtain reimburse for excess loss medical claims on behalf of the Company’s Trust and Employer Groups associated under Third Party Administrator (TPA). This position is also the subject matter expert for the team in reviewing supporting documentation, client, and reinsurance reporting.

Duties And Responsibilities

Specific Claim Submission

• Gather, organize, and review all necessary claim information required to submit excess loss claims (stop loss claims) to various individual Reinsurance Carriers to insure maximum reimbursement.
• Submit claims, following Carrier Guidelines, based on reports generated after each payment run.
• Respond to internal/external customer inquiries and requests within the department-established timeframe.
• Troubleshoot for potential departmental policy and procedure issues.
• Ensure claims processed within the MEWA, ERISA, and California Department of Insurance standards, as they apply.
• Support clients, carriers and brokers at every step involved in completion of the claim reimbursement process.
• Monitor large case management files with utilization review, eligibility unit and claims examiners.
• Answer inquires related to Advance Funding.

Reporting and End of Contract Review

• Prepare and send required monthly specific and aggregate stop loss reports for brokers, carriers, and clients.
• Create special ad hoc report requests.
• Ensure timely responses to customer inquiries and requests for data information.
• Analyze claims data, diagnosis reports and utilization review data to identify potential high dollar claimants.
• Create potential high dollar report required as monthly distribution to Reinsurance Carriers.
• Prepare and provide last quarter reporting to Account Managers as they prepare for client renewal.
• Identify and notify Account Managers, clients, and brokers of priority claims at year end to insure maximum reimbursement.
• Identify potential ongoing high dollar claimants for disclosure at renewal.

Quality Results

• Monitor the reinsurance process to ensure timely filings occur and year-end process meets client needs.
• Monitor catastrophic health claims for PCMI & WGAT to eliminate the possibility of lost reimbursements.
• Analyze high dollar claims to ensure maximum and prompt reimbursement.
• Meet “Scheduled Adherence” average monthly metrics.
• Meet “Conformance” average monthly metrics.
• Monitor for prompt reimbursement receipt (goal 18 days) of reporting submission documents.
• Audit Carrier response to ensure accurate reimbursement and submit payment appeal if necessary.

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.
• 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

• High school education or equivalent and minimum of two (2) to five (5) years of experience as a medical/dental claims auditor/investigator and/or medical insurance account management/sales.
• Basic knowledge of word processing, spreadsheet, presentation media and end-user office software.
• Ability to work under pressure and adapt to a changing environment.
• Knowledge and experience of International Statistical Classification of Diseases and Related Health Problems (ICD-9, ICD-10), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS II & III), coordination of benefits, Medicare, Hospital claims, surgery claims, subrogation, and accident claims.
• Proficient with terminology comprehension.
• Good verbal and written communication skills.
• Working knowledge of Employee Retirement Income Security Act of 1974, (ERISA) claims processing/adjudication guidelines.
• Exceptional organizational, time management, critical thinking, and problem-solving skills.
• Knowledge of client specific, potential, and aggregate reporting under reinsurance a plus.