Description:Part of the Western Growers Family of Companies, Western Growers Assurance Trust (WGAT) was founded in 1957 to provide a solution to a need in the agricultural community — a need for employer-sponsored health benefit plans not previously available from commercial health insurance carriers. WGAT is now the largest provider of health benefits for the agriculture industry. The sponsoring organization of WGAT is Western Growers Association, created in 1926 to support the business interests of employers in the agriculture industry. WGAT’s headquarters is located in Irvine, California.

WGAT’s mission is to deliver value to agriculture-based employer groups by offering robust health plans that meet the needs of a diverse workforce. By working at WGAT, you will join a dedicated team of employees who truly 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 WGAT today!

Compensation: $45,091 - $63,617 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

The Senior Claims Examiner will process large dollar/complex health care claims, adjustments and contracts that require higher degree of accuracy. This incumbent will thoroughly review, analyze, and research complex health care claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. They will assist in resolving escalated issues including making and answering phone calls to providers/billing offices when necessary based on team guidelines. The Senior Claims Examiner will work on special projects related to provider and plan documents, system upgrades, implementing initiatives to improve claims processing, and turnaround times. They will mentor other team members and lead aspects of training functions and Subject matter expert in a variety of knowledge sets and process improvement activities.

Qualifications

• High school education or equivalent and five (5) to seven (7) years of experience as a health claims examiner or comparable industry experience.
• Advance level (minimum 5 years) of claims processing experience and understanding of medical, dental, FSA, HRA, transplant, coordination of benefits, Medicare, hospital, professional, subrogation, and accident claims required.
• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination
• Proficient in medical terminology, contract and benefit interpretation, UB-04 and HCFA 1500 forms (837/5010 format), medical coding, CPT, ICD10, HCPCS, DRG, National Correct Coding Initiative (NCCI) edits or Medically Unlikely Edits (MUE), with working knowledge of Federal, State and Self-funded insurance plans.
• Excellent verbal, written and interpersonal communications skills to communicate effectively with individuals at all levels of the organization, as well as front line health plan contacts.
• Proficient in 10-key by touch data entry/typing and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.
• Exceptional time management, multi-task, critical thinking, problem solving skills and ability to work under pressure and adapt to changing environment.
• Working knowledge of Employee Retirement Income Security Act of 1974, (ERISA) claims processing/ adjudication guidelines.

Duties And Responsibilities

Claims Processing & Quality Assurance

• Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), FSA, foreign claims, outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, and Medicare Secondary Payer (MSP) by calculating benefit due to approve or deny, based on SPD.
• Research written and/or verbal queries from providers/members/internal departments to determine appropriate action on claim and process corrections as required.
• Analyze patient and medical information to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly.
• Examine claim files for accuracy and make necessary adjustments and corrections: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation. 
• Review and release High dollar claim or other complex claims adjudicated by less senior examiners as directed by the Team