Western Growers Health─a part of Western Growers Family of Companies─provides employer-sponsored health benefit plans to meet the needs of those working for the agriculture industry. The unmatched benefit options provided by Western Growers Health stem from the core mission of Western Growers Association (est. 1926) to support the business interests of employers in the agriculture industry.

Our mission at Western Growers Health is to deliver value to employers by offering robust health plans that meet the needs of a diverse workforce. By working at Western Growers Health, you will join a dedicated team of employees who 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 Western Growers Health today!

Compensation: $40,580.28 - $57,756.02 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

Reports to the Nurse Supervisor and assists in the process of health management and utilization review (UR). The incumbent will accomplish this by entering pre-service, concurrent, and post-service requests received from health care providers for medical services, and completing selected authorizations as directed by the UR Nurses. Reach out to both potential and existing Health Management (HM) members to arrange appointments with the HM coaching team. Keep track of incoming service inquiries and deliver outstanding customer service to both our internal and external clients.

Qualifications

• High school education or equivalent and/or two years’ experience in health insurance environment.  
• Experience in Utilization or Case Management Department interacting with clinical staff.
• Good understanding of health benefits claims processing, knowledge and understanding of current procedural terminology (CPT), healthcare common procedure coding system (HCPCS) and international classification of diseases (ICD) 9/10 codes preferred.
• Good understanding of generally accepted medical practices and knowledge of state and Employee Retirement Income Security Act (ERISA) mandated benefits, plan language and contracts preferred.
• Good knowledge of medical terminology, hospital, clinic or laboratory procedures preferred.
• Proficient in Microsoft Office (Word, Excel, Outlook) and electronic health record software.
• Detail oriented with strong analytical skills.            
• Motivated self-starter with the ability to work independently, as well as, part of a team.      
• Excellent verbal and written communication skills.
• Proficiency in both English and Spanish is required.
• Comprehensive command of the Spanish language with the ability to utilize it up to 50% of the time.
• 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

Administrative Support

• Review all utilization requests and forward, research, and analyze to determine if clinical or administrative in nature. Forward clinical issues to the appropriate staff for processing and handle administrative issues as appropriate.
• Enter accurate and complete authorization information into the system. Generate member and provider approval letters, as appropriate.
• Clarify CPT, HCPCS, and ICD-10 codes with conflicting, missing, or unclear information by consulting with provider’s staff. Maintain positive relationships with provider offices.
• Determine the eligibility of the member and resolve questionable eligibility with Administration department, as appropriate.
• Transmit correspondence or medical records by mail, e-mail, or fax.
• Assess network status of requested providers. If non-network, determine if alternate network providers are available to provide same service. Communicate non-network status to requesting provider and ensure member is aware of same.  
•  Protect the security of medical records to ensure that confidentiality is maintained.

Operational Support

• Work with Claims, Customer Service, Provider Maintenance and Contracting staff to provide complete information necessary for clinical review.
• Complete letter of ag