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: $61,719.12 - $85,234.24 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 Claims Operations Analyst reports to the Manager, Claim Operations. The Claims Operations Analyst ensures the operational effectiveness of the Claims department by driving process improvements, documenting business processes, and troubleshooting electronic data file outputs. The incumbent is responsible for defining business requirements, obtaining approvals, and collaborating with IT to implement solutions. Additionally, this position performs root cause analysis for claims quality remediation and supports the implementation of new processes and technologies.

Qualifications

• Bachelor’s degree (BA/BS) in business, health care, or related field and three (3) years’ experience in a Third-Party Administrator (TPA), health plan, or health insurer supporting operations as an analyst; preferred.
• In-depth knowledge of health care claims processing technology & processes (e.g., claims processing systems, plan design, workflows, work queues, robotic automation, and standard operating processes).
• Comprehensive experience working with the Anthem Blue Card program, processes & technology, preferred.
• Six Sigma belt, agile, or project management experience or certification preferred.
• Advanced skills with workflow software (e.g., VISIO), creating presentations, or analyzing data using excel or other tools is a plus.
• Excellent written and oral communication skills to communicate effectively with senior leaders.
• Strong attention to detail and the ability to analyze and document complex business processes.
• Excellent planning and organizational skills.
• Analytical and problem-solving skills.
• Ability to interpret business needs and translate those needs to requirements.
• 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.
• A functioning smoke detector, fire extinguisher, and first aid kit on site.

Duties and Responsibilities

Claims Department Support

• Review the performance of vendors supporting the claim function, including monitoring the performance of electronic data interchange (EDI) transactions and working with the business to troubleshoot errors and rejections from vendors and network partners.
• Evaluate the effectiveness of claims processing, quality assurance processes, and payment integrity programs through data and reports.
• Analyze data to generate KPI and dashboard metrics and reports at required intervals for claims leadership, claims staff, and other key individuals.
• Plan and implement user acceptance testing, including documentation, verification, and updates.
• Collaborate with other business areas to monitor cross-department workflow and hand-off, identifying areas of waste, inefficiencies, or errors.
• Support Claims leadership in root cause analysis of claim deficiencies and recommend solutions.
• Monitor 835 & 837 error reports, correcting discrepancies and identifying opportunities to reduce error rates.
• Monitor requirements and changes to requirements from network partners to evaluate impact to workflow, processes and effectuate required changes within Claims and with IT partners.

Process Improvement

• Analyze and assist with process improvement activities and the identification of efficient and effective methods of business operations, including manual processes and system automation, auto-adjudication, workflow queue rules, and claim edits.
•  Complete the