Western Growers

Customer Support

• Respond to general customer questions via telephone, e-mail, and written correspondence regarding insurance benefits, provider contracts, reimbursement programs, eligibility, and claims in a confidential, professional, and ethical manner.
• Analyze problems and provide information/solutions.
• Research and resolve aged Customer Service open calls within company standards.
• Operate in the Health Care Processing System (HCPS), Imaging systems, and all systems necessary to obtain and extract information with proficiency and skills.
• Develop and maintain positive customer relations and coordinate with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
• Be accountable when you uncover an issue or trend by helping to assess and report its impact, making improvements, and course-correcting along the way.
• Follow quality guidelines to provide exceptional customer support and ensure scores meet or exceed expectations.
• Accurately document database activity and customer interaction for tracking and analysis to identify trends and address operational and service issues.
• Research and analyze data to address standard operational challenges and customer service issues.
• Provide customers with requested information, including difficult and upset customers.
• Meet or exceed all department and performance service metrics.
• Communicate with the appropriate departments and identify service issues.
• Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
• Maintain regular attendance per employee handbook guidelines.
• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members.

Customer Service Representative, Pacific/Mountain Time Zone

• Respond to customer inquiries regarding insurance benefits and claims
• Analyze problems and provide solutions
• Research and resolve aged Customer Service calls
• Operate in Health Care Processing System and various needed systems
• Develop positive customer relations and coordinate with various functions
• Document database activity for analysis
• Identify inefficiencies within processes and suggest solutions
• Maintain regular attendance

Customer Service Representative I

Medical Billing and Coding

• plan code new business and plan changes
• 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
• respond to work orders received from examiners to investigate plan issues and irregularities
• evaluate testing requests for all new plans prior to loading them into the production system
• keep a detailed log of open and completed work
• document resolutions to closed work orders
• identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses
• create and document a minimum of one new Standard Operating Procedure (SOP) annually
• identify, initiate and implement at least one process improvement and/or innovation annually
• maintain detailed log of plans that are currently being coded and in the process of being loaded
• send confirmations to internal stakeholders when applicable plans have been loaded
• work with programmers to test claims and related system programs to verify impact within the Health Care Processing System (HCPS)
• utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members

Coder

Auditor

• Perform in-depth plan coding and testing of new and existing business accounts
• Ensure compliance with the respective employers’ summary plan descriptions for health insurance plans
• Verify new and existing plans loaded on the Company’s claim management system against the appropriate Summary Plan Description
• Test all new plans prior to loading them into production
• Work with programmers to test claims and related system programs
• Communicate with other operational departments to ensure smooth integration of new plans
• Provide monthly reporting of all requested plan issues submitted from the Claims department
• Identify inefficiencies within established processes and suggest solutions
• Create and document Standard Operating Procedures (SOP)
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data

Implementation Auditor

Financial Planning and Analysis

• Process financial transactions, both automated and manual, within the company’s processing systems, including group and individual billing, Automated Clearing House (ACH) transactions, and cash receipt processing
• Maintain and balance group and individual accounts receivables including delinquency processing and terminations
• Manage receipt of group admin fees and process vendor payments
• Invoice for third party administrator (TPA) Claims processing and manage receipt and application of claims funding
• Maintain/manage all Pinnacle Claims Management, Inc. (PCMI) contribution/premium reimbursements, COBRA/Retiree reimbursements, and vendor pass thru payments for PCMI
• Verify and authorize the release of PCMI vendor payment within four business days of account funding
• Manage the process of funding and releasing self-funded claims payments
• Reconcile and maintain accuracy of group ledger accounts by matching incoming payments to corresponding invoices, promptly investigating and resolving discrepancies, collaborating with internal teams and external partners to make adjustments, and maintaining thorough documentation to support audit trails
• Monitor bank accounts daily for returned items, overdrafts, positive pay exceptions, stop payments and other exception reporting and make decision for resolution or escalation
• Month End Financials completed and delivered to Accounting by the fifth (5 th ) business day of the month
• Assist with Mid-Month cash application audit that must be completed by the 15 th business day of the month
• Manage and maintain Bank lockbox, and ACH/Wire programs
• Manage and maintain retiree invoicing & receivable management program(s)
• Support FSA (Flexible Spending Account) HSA (Health Savings Account) HRA (Health Reimbursement Arrangement) program
• Manage the delinquency process for both WGH & PCMI accounts
• Manage the third-party pharmacy process by reviewing consumer claim data files from vendors and coordinating billing and invoicing between operational and accounting teams to ensure accurate and timely payments.
• Validate and audit pharmacy data files against contract pricing, documenting, and reporting findings
• Prepare ad hoc reports upon request
• Proactively identify inefficiencies within established processes and recommend solutions to optimize time, reduce risk, and minimize cost

Financial Specialist II

Claims Specialist

• The Claims Examiner I reports to the Supervisor of Claims.
• Claims Examiner I is responsible for reviewing and processing medical, dental, vision, and electronic claims per state, federal, and health plan regulatory requirements and department guidelines, as well as meeting established quality and production performance benchmarks, including research and review of applicable documentation.
• The Claims Examiner I will thoroughly review, analyze, and research health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment.
• The position will assist in resolving issues from providers, customer service, member services, health plan, and other internal customers.