Claims Auditor

JOB DESCRIPTION

SUMMARYThis position reports to the Supervisor of Claims and performs in-depth audits to ensure existing health (medical/dental) benefit plans of Western Growers Assurance Trust and Pinnacle Claims Management, Inc. clients are in compliance with the respective employers’ summary plan descriptions.

Qualifications

• BS/BA degree preferred and a minimum of one (1) to three (3) years of recent experience as a medical/dental claims auditor.
• Three (3) years’ experience processing group health claims preferred.
• Knowledge of Current Procedural Terminology (CPT) and International Statistical classification of Diseases and Related Health Problems (ICD-10 & ICD-9) and medical terminology.
• Exceptional understanding and interpretation of summary plan descriptions of employee medical/dental benefits.
• Good ability to interpret provider contracts.
• Proven ability as a self-starter to manage timelines and commitments.
• Proficient in end-user software, ., word-processing and spreadsheets.
• Exceptional written and verbal communication skills.
• Good knowledge of basic business math.

Duties And Responsibilities

Claims Auditing

• Perform routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory and timelines standards, business policy, and contract terms.
• Ensure appropriate coding and system configuration of claims with the ability to extract and audit exception audit reports.
• Research claim processing problems and errors to determine their origin and appropriate resolution.
• Prepare reports and summarize observations and recommendations for management.
• Participate in communication with management regarding trends in order to improve claims processing accuracy and documented business rules for incorporation into training programs, policies, and procedures.
• Perform special project audits and reviews as requested by other departments/regions.

Claims Department Support

• Identify and escalate issues related to instructional material that is inaccurate, unclear or contains gaps and provide recommendations for correction of this material.
• Confer with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.
• Participate in departmental error logs analytics and includes the findings in training preparations.
• Provide technical support, training assistance, and expertise to claims staff or other department as determined through audit findings.
• Support and assist management team in updating department policies and guidelines.

Pinnacle Risk Management Services – Claims – PM6000

• Adjudicate specific stop loss claims received from Third Party Administrators in accordance with stop loss policy terms and the plan document. Process complex claims for physician, hospital, and specialty areas with high degree of accuracy and productivity.
• Process stop loss claim adjustments, refunds, and checks according to company policies and procedures, within established dollar authority.
• Respond and assist with claim documentation and reports as needed.
• Identify process improvement opportunities and works to implement corrective actions.
• Coordinate and communicate claims status with reinsurance carrier.
• Work with AVP of Claims, Claims Manager and Reinsurance Analyst as required

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 helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
• All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here represent those that an employee must meet to perform this job’s essential functions successfully. 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 communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.#LI-Remote