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: $39,208 - $55,972 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 Examiner II reports to the Supervisor of Claims. Claims Examiner II is responsible for reviewing and processing medical, dental, vision and electronic claims in accordance with state, federal and health plan regulatory requirements, department guidelines, as well as meet established quality and production performance benchmarks to include research and review of applicable documentation. This position will thoroughly review, analyze, and research health care claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The Claims Examiner II will assist in resolving escalated issues from provider customer service, member services, health plan, and other internal customers

Qualifications

• High school education or equivalent with five (5) to seven (7) years of experience as a health claims examiner or comparable industry experience preferred.
• A minimum of two 2 years’ experience as a claim’s examiner for medical, dental and vision claims, coordination of benefits, Medicare, subrogation, and accident claims
• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination
• Excellent knowledge of medical terminology.  Familiar with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
• Good verbal and written communication skills.
• Proficient in 10-key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.
• 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.
• 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

Claims Processing & Quality Assurance

• Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, 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.
• Review reports and research pending claims to ensure timely adjudication within accepted corporate cycle times. Reports include, but are not limited to, daily and pending reports, weekly cumulative pend, and other special reports as received from customer.
• Analyze patient and medical records 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, perform complete file reviews when appropriate. 
• Review and release High dollar claim or other complex claims as directed by the Claims Management.
• Research