Implementation Auditor

Description

If you're looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we're looking for you.

At Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.

As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn't a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee's life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options.

With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees' job satisfaction and success.

Compensation: $45,091 - $63,617 with a rich benefits package that includes profit-sharing

Job Description Summary

Position reports to the Supervisor, Benefit Installation & Distribution and performs in-depth plan coding and testing of new and existing business accounts. This position will ensure that all new and existing health (medical/dental) insurance plans underwritten by the Western Growers Assurance Trust (WGAT) and those of Pinnacle, Inc. (PCMI) are in compliance with the respective employers' summary plan descriptions.

Qualifications

• BS/BA degree in Business or related field and a minimum of three (3) to (5) five years of recent experience as a medical/dental claims auditor or plan testing experience, preferred.
• Exceptional understanding and ability to interpret summary plan descriptions of employee medical/dental benefits.
• Strong ability to work efficiently and effectively in a multiple task, multi-project, and multi-demandingenvironment to meet expected goals, dates, and milestones.
• Ability to anticipate problems, recommend solutions, and exercise best judgement.
• Excellent writing, editing, and proofreading skills to compose and edit correspondence, reports, emails, and other written materials.
• Proficient ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts.
• Previous experience with conducting research and presenting complex information.
• Excellent communication and interpersonal skills.
• Superior organization skills and high attention to detail.
• Ability to learn complex business processes and appropriately apply knowledge to make informed decisions.
• Advanced skills in Microsoft Office applications.
• Knowledge of medical terminology. Familiar with ICD10, CPT, HCPC, and CDT codes.
• 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

Testing

• Using close and comprehensive analyses, verify new and existing plans loaded on the Company's claim management system against the appropriate Summary Plan Description to determine the accuracy of present and future claims payments.
• Test all new plans prior to loading them into production (medical, dental and vision plans).
• Work with programmers to test claims and related system programs to verify impact within the HCPS.
• System analysis and testing of mass system updates.
• Plan coding of new business and plan changes for medical, dental, and vision plans.
• Communicate with other operational departments, as necessary, to ensure smooth integration of new plans for both WGAT and PCMI moving into production.

Reporting

• Provide monthly reporting of all requested plan issues submitted from the Claims department.
• Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
• Create and document Standard Operating Procedures (SOP).
• Identify, initiate and implement process improvements and/or innovation.

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.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit)
• All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job 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.