If you’re looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we’re looking for you.
At Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full-suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.
As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn’t a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee’s life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options.
With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees’ job satisfaction and success.
Compensation: $ 61,719.12 - $ 80,234.24 with a rich benefits package that includes profit-sharing.
This position reports to the Manager of Payment Integrity and performs in-depth quality claim audits to ensure company standards are being met along with providing support in recovery and receivables. In addition, this position will provide reporting and training support to the Claims Department.
QUALIFICATIONS
• High school Diploma or equivalent and a minimum four (4) to six (6) years of recent experience as a medical, dental, vision and specialty claims auditor. Six years’ experience processing group health claims, preferred.
• Strong knowledge of basic revenue and receivables business math and operations. Accounting or Receivables background preferred.
• Knowledge of Current Procedural Terminology (CPT) and International Statistical classification of Diseases and Related Health Problems (ICD 11 & ICD-10 & ICD-9) and medical terminology.
• Strong understanding of CMS, HIPAA, MEWA, ERISA, and Perspective Payment Systems reimbursement regulations and compliance.
• Exceptional understanding and interpretation of summary plan descriptions of employee
medical/dental/vision and specialty benefits.
• Basic familiarity with electronic data interchange (EDI) transactions (e.g., 835 and 837 files), preferred.
• Exceptional ability to interpret provider contracts, plan documents, respond to questions and train in depth claim form issues.
• Proven ability as a self-starter to manage timelines and commitments.
• Proficient in end-user software, e.g. word-processing and spreadsheets.
• Exceptional written and verbal communication skills.
• Ability to apply critical thinking and demonstrate sound judgement in a variety of situations.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client data.
• 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
Process Management & Oversight
• Identify and escalate issues related to instructional and claims procedures, work
instructions, or workflows that are inaccurate, unclear, contain gaps, or have not been
created.
• Provide support in enhancing Payment Integrity guidelines and workflows.
• Facilitate the development of process documentation.
• Document business rules for incorporation into training programs, policies and
procedures.
• Provide research and root cause analysis for claims quality remediation.
• Perform special project audits and reviews, including auditing selected claims before the
nightly payment run, as requested by claims leadership.
• Monitor standard EDI error and rejection reports and make corrections as assigned.
• Monitor 835 & 837 error reports, correcting discrepancies and identifying opportunities
to reduce error rates.
• Lead operational oversight of network payment posting and reconciliation, driving consistency, accountability, and performance.
Department Operations
• Perform moderately and highly complex audits on paper and electronic claims for
payment integrity in alignment with regulatory and timelines standards, business policy,
and contract terms.
• Research claim processing problems and errors to determine their origin and appropriate
resolution. Communicate with management regarding trends to improve claims
processing accuracy.
• Research, review and analyze all overpayments, refunds and voids relating to medical,
dental, and vision claims.
• Provide support to collect receivables for the Western Growers Assurance Trust (WGAT)
and clients of the Third-Party Administrator (TPA) that may be a result of overpayments or
claims adjustments by researching, writing letters, and actively making phone calls.
• Research and respond to inquiries from other departments related to claim financial
transactions within the required turn-around time.
• Prepare reports, summarize observations and prepare recommendations for
management.
• Perform special project audits and reviews as requested by other departments/regions.
• Perform review and audit of Payment Integrity Staff work via “Audit the Payment Integrity
Team” program.
Coaching & Development
• Provide Subject Matter Expert (SME) support for new hire training, individual, and uptraining classes.
• Assist existing staff with claims questions and complex claims topics.
• Provide support to the training team with new hires, Nesting Team, and up-training
curriculum recommendations.
• Participate in claims staff development and performance improvement plans by providing
additional auditing and coaching.
• Support the development of a culture of accountability by modeling the behavior that
defines it.
• Participate in developing and leading a team of 3A+ self-accountable professionals.
• Participate in team meetings and one-one conversations along with the Manager of
Payment Integrity.
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 in a helpful and collaborative manner, being willing to adjust efforts to
ensure that work and attitude are helpful to others, being self-accountable, creating
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 complaint 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 successfully perform the essential functions of this job. 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 talk or hear. The employee frequently is required to stand, walk
and sit. The employee is frequently required to use hands to finger, handle, or feel objects, tools, or controls and reach with hands and arms. The noise level in the work environment is usually moderate.
Western Growers exists for one reason only: to ensure the future viability of its members – the hard-working, salt-of-the-earth farmers who grow the fruits, vegetables and tree nuts that feed our nation and nourish our bodies. But their way of life, their ability to pass their multi-generational farms and family legacies on to their children and grandchildren, is being jeopardized by a host of threats, many of them beyond their control. They face a growing litany of laws and regulations that make it increasingly difficult and expensive to do business.
Our members depend on us to help them remain competitive and profitable in spite of these trying circumstances, which we do by fighting – heart and soul – for them every single day. We passionately advocate for them in the halls of Congress and on the steps of the state capitol. We actively facilitate the advancement of technology designed to help them become more efficient and less dependent on diminishing resources. We diligently provide health insurance to their farm workers, as well as other insurance solutions tailored to the unique business. We do all of this, and more, from a position of leadership in the agriculture industry, which requires a team of intelligent, inquisitive and innovative individuals committed to our common purpose.
Western Growers was founded in 1926 and is headquartered in Irvine, California with offices in Bakersfield, Fresno, Imperial, Modesto, Sacramento, Salinas and Santa Maria, California along with offices in Phoenix and Somerton, Arizona, and Washington, D.C.
