Lead, Payment Integrity

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: $ 61,719.12 - $ 80,234.24 with a rich benefits package that includes profit-sharing. 

JOB DESCRIPTION SUMMARY

This position reports to the Manager of Payment Integrity and performs in-depth quality claim audits to ensure company standards are being met along with providing support in recovery and receivables. In addition, this position will provide reporting and training support to the Claims Department.

QUALIFICATIONS

• High school Diploma or equivalent and a minimum four (4) to six (6) years of recent experience as a medical, dental, vision and specialty claims auditor. Six years’ experience processing group health claims, preferred.

• Strong knowledge of basic revenue and receivables business math and operations. Accounting or Receivables background preferred.

• Knowledge of Current Procedural Terminology (CPT) and International Statistical classification of Diseases and Related Health Problems (ICD 11 & ICD-10 & ICD-9) and medical terminology.

• Strong understanding of CMS, HIPAA, MEWA, ERISA, and Perspective Payment Systems reimbursement regulations and compliance.

• Exceptional understanding and interpretation of summary plan descriptions of employee

medical/dental/vision and specialty benefits.

• Basic familiarity with electronic data interchange (EDI) transactions (e.g., 835 and 837 files), preferred.

• Exceptional ability to interpret provider contracts, plan documents, respond to questions and train in depth claim form issues.

• Proven ability as a self-starter to manage timelines and commitments.

• Proficient in end-user software, e.g. word-processing and spreadsheets.

• Exceptional written and verbal communication skills.

• Ability to apply critical thinking and demonstrate sound judgement in a variety of situations.

• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client data.

• 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

Process Management & Oversight

• Identify and escalate issues related to instructional and claims procedures, work

instructions, or workflows that are inaccurate, unclear, contain gaps, or have not been

created.

• Provide support in enhancing Payment Integrity guidelines and workflows.

• Facilitate the development of process documentation.

• Document business rules for incorporation into training programs, policies and

procedures.

• Provide research and root cause analysis for claims quality remediation.

• Perform special project audits and reviews, including auditing selected claims before the

nightly payment run, as requested by claims leadership.

• Monitor standard EDI error and rejection reports and make corrections as assigned.

• Monitor 835 & 837 error reports, correcting discrepancies and identifying opportunities

to reduce error rates.

• Lead operational oversight of network payment posting and reconciliation, driving consistency, accountability, and performance.

Department Operations

• Perform moderately and highly complex audits on paper and electronic claims for

payment integrity in alignment with regulatory and timelines standards, business policy,

and contract terms.

• Research claim processing problems and errors to determine their origin and appropriate

resolution. Communicate with management regarding trends to improve claims

processing accuracy.

• Research, review and analyze all overpayments, refunds and voids relating to medical,

dental, and vision claims.

• Provide support to collect receivables for the Western Growers Assurance Trust (WGAT)

and clients of the Third-Party Administrator (TPA) that may be a result of overpayments or

claims adjustments by researching, writing letters, and actively making phone calls.

• Research and respond to inquiries from other departments related to claim financial

transactions within the required turn-around time.

• Prepare reports, summarize observations and prepare recommendations for

management.

• Perform special project audits and reviews as requested by other departments/regions.

• Perform review and audit of Payment Integrity Staff work via “Audit the Payment Integrity

Team” program.

Coaching & Development

• Provide Subject Matter Expert (SME) support for new hire training, individual, and uptraining classes.

• Assist existing staff with claims questions and complex claims topics.

• Provide support to the training team with new hires, Nesting Team, and up-training

curriculum recommendations.

• Participate in claims staff development and performance improvement plans by providing

additional auditing and coaching.

• Support the development of a culture of accountability by modeling the behavior that

defines it.

• Participate in developing and leading a team of 3A+ self-accountable professionals.

• Participate in team meetings and one-one conversations along with the Manager of

Payment Integrity.

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 in a helpful and collaborative manner, being willing to adjust efforts to

ensure that work and attitude are helpful to others, being self-accountable, creating

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 complaint 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 successfully perform the essential functions of this job. 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 talk or hear. The employee frequently is required to stand, walk

and sit. The employee is frequently required to use hands to finger, handle, or feel objects, tools, or controls and reach with hands and arms. The noise level in the work environment is usually moderate.