(No Diploma Required! πŸŽ‰) Get Paid $2,630.75

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Claims Examiner I

Claims Distant, United States Fresno, California

A part of the Western Growers Household of Corporations, Western Growers Assurance Belief (WGAT) was based in 1957 to supply an answer to a necessity within the agricultural neighborhood β€” a necessity for employer-sponsored well being profit plans not beforehand obtainable from industrial medical insurance carriers. WGAT is now the biggest supplier of well being advantages for the agriculture business. The sponsoring group of WGAT is Western Growers Affiliation, created in 1926 to help the enterprise pursuits of employers within the agriculture business. WGAT’s headquarters is situated in Irvine, California.

WGAT’s mission is to ship worth to agriculture-based employer teams by providing strong well being plans that meet the wants of a various workforce. By working at WGAT, you’ll be a part of a devoted crew of staff who really care about providing high quality well being advantages and glorious customer support to plan individuals. If you wish to begin making a distinction working within the well being care business, then apply to WGAT in the present day!

Compensation: $31,569 – $46,040 with a wealthy advantages bundle that features profit-sharing.


The Claims Examiner I reviews to the Supervisor of Claims. Claims Examiner I is accountable for reviewing and processing medical, dental, imaginative and prescient and digital claims in accordance with state, federal and well being plan regulatory necessities, division pointers, in addition to meet established high quality and manufacturing efficiency benchmarks to incorporate analysis and evaluation of relevant documentation. The incumbent may even course of Well being Insurance coverage Fee Demand (HIPD) claims. The Claims Examiner I’ll totally evaluation, analyze, and analysis well being care claims with the intention to determine discrepancies, confirm pricing, verify prior authorizations, and course of them for cost. The place will help in resolving points from suppliers, customer support, member providers, well being plan, and different inner clients.


  • Highschool schooling or equal: minimal one (1) to a few (3) years yr of expertise as a Well being Claims Examiner or comparable business expertise most popular.

  • A minimal of 1 (1)yr expertise as a Claims Examiner for medical, dental claims and imaginative and prescient, subrogation, and accident claims

  • Means to interpret Plan Paperwork or Abstract Plan Descriptions (SPD) for the aim of correct declare adjudication and/or profit dedication

  • Primary information of medical terminology. Acquainted with UB-04 and HCFA 1500 types (837/5010 format), ICD10, CPT, and HCPCS codes.

  • Good verbal and written communication abilities.

  • Proficient in 10-key by contact information entry/kind 40 WPM and Microsoft Workplace (Phrase, Excel, Outlook, PowerPoint) and possess a functionality to rapidly be taught new purposes.

  • Means to work below strain and adapt to altering surroundings

  • Working information of Worker Retirement Earnings Safety Act of 1974 (ERISA) claims processing/adjudication pointers.

Duties And Tasks
Claims Processing & High quality Assurance

  • Adjudicate all claims varieties together with Dental, Imaginative and prescient and Medical claims for inpatient and outpatient services, doctor claims, In and Out of Community claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident and Third-Occasion Legal responsibility (TPL) claims, by calculating profit attributable to approve or deny, based mostly on SPD and inside accepted company cycle timeframe.

  • Analyze affected person and medical data to determine situations the place investigation for figuring out acceptable Declare Advantages, Pricing, Prior Authorization or Coordination of Advantages is critical and course of claims accordingly.

  • Look at declare recordsdata for accuracy: verifications (i.e. eligibility, medical authorization, and many others.); attain out to Well being Care Suppliers to acquire needed claims documentation.

  • Resolve profit and eligibility points that require detailed information, help for purchasers throughout the claims processing, Firm and ERISA pointers. Course of low stage claims, re-pricing corrections.

  • Analysis and full all correspondence associated to digital and paper claims as

  • Preserve a Well being Insurance coverage Portability and Accountability Act (HIPAA) compliant workstation. Make the most of acceptable safety strategies to make sure HIPAA required safety of all confidential/protected shopper and enrollee information.

  • Meet and preserve particular person and division productiveness and high quality requirements.

Downside Fixing, Judgement & Compliance

  • Look at an issue, set of information or textual content and think about a number of sides of a problem, weighs penalties earlier than making a last determination.

  • Guarantee compliance with all acceptable insurance policies and practices, native, State, Federal rules and necessities relating to claims and contract administration.

  • Accomplice with friends to doc and analyze purposeful necessities, determine gaps and various approaches to resolve issues.

  • Contribute to defining and documenting requirements and periodically reviewing them to combine acceptable business requirements.

  • Alert supervisors to potential greater threat compliance points

  • Make well timed and efficient choices based mostly on obtainable data

  • Acknowledge points, analyzes, solves issues, researches, identifies developments and determines actions wanted to advance the decision-making course of inside a practical timeframe. Follows up as needed.

  • Contain the suitable folks in defining, understanding the impression and resolving issues.


  • Make the most of all capabilities to fulfill one mission β€” to reinforce the competitiveness and profitability of our members. Do all the things attainable to assist members succeed by being curious and striving to know what others are attempting to realize, planning, and executing work helpfully and collaboratively. Be keen to regulate efforts to make sure that work and angle are useful to others, being self-accountable, making a optimistic impression, and being diligent in delivering outcomes.

  • All different duties as assigned.

Bodily Calls for/Work Atmosphere
The bodily calls for and work surroundings described listed below are consultant of those who have to be met by an worker to carry out the important capabilities of this job efficiently. Affordable lodging could also be made to allow people with disabilities to carry out the important capabilities. Whereas performing the duties of this job, the worker is usually required to speak with others. The worker regularly is required to maneuver across the workplace. The worker is usually required to make use of instruments, objects, and controls. This noise stage within the work surroundings is normally average.

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