Company

Western Growers Family Of CompaniesSee more

addressAddressRemote
salary Salary$41,751 - $59,275 a year
CategoryEducation/Training

Job description

Part of the Western Growers Family of Companies, Western Growers Assurance Trust (WGAT) was founded in 1957 to provide a solution to a need in the agricultural community — a need for employer-sponsored health benefit plans not previously available from commercial health insurance carriers. WGAT is now the largest provider of health benefits for the agriculture industry. The sponsoring organization of WGAT is Western Growers Association, created in 1926 to support the business interests of employers in the agriculture industry. WGAT’s headquarters is located in Irvine, California.
WGAT’s mission is to deliver value to agriculture-based employer groups by offering robust health plans that meet the needs of a diverse workforce. By working at WGAT, you will join a dedicated team of employees who truly care about offering quality health benefits and excellent customer service to plan participants. If you want to start making a difference working in the health care industry, then apply to WGAT today!
Compensation: $41,751 - $59,275 with a rich benefits package that includes profit-sharing.This is a remote position and can reside anywhere in the U.S.

JOB DESCRIPTION SUMMARY

Reports to the Nurse Supervisor and assists in the process of health management and Utilization Review (UR). The incumbent will accomplish this by entering pre-service, concurrent, and post-service requests received from health care providers for medical services, and completing selected authorizations as directed by the UR Nurses. Reach out to both potential and existing Health Management (HM) members to arrange appointments with the HM coaching team. Keep track of incoming service inquiries and deliver outstanding customer service to both our internal and external clients.

Qualifications

  • High school education or equivalent and/or two years’ experience in health insurance environment.
  • Experience in Utilization or Case Management Department interacting with clinical staff.
  • Good understanding of health benefits claims processing, knowledge and understanding of current procedural terminology (CPT), healthcare common procedure coding system (HCPCS) and international classification of diseases (ICD) 9/10 codes preferred.
  • Good understanding of generally accepted medical practices and knowledge of state and Employee Retirement Income Security Act (ERISA) mandated benefits, plan language and contracts preferred.
  • Good knowledge of medical terminology, hospital, clinic or laboratory procedures preferred.
  • Proficient in Microsoft Office (Word, Excel, Outlook) and electronic health record software.
  • Detail oriented with strong analytical skills.
  • Motivated self-starter with the ability to work independently, as well as, part of a team.
  • Excellent verbal and written communication skills.
  • Proficiency in both English and Spanish is required.
  • 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

Administrative Support
  • Review all utilization requests and forward, research, and analyze to determine if clinical or administrative in nature. Forward clinical issues to the appropriate staff for processing and handle administrative issues as appropriate.
  • Enter accurate and complete authorization information into the system. Generate member and provider approval letters, as appropriate.
  • Clarify CPT, HCPCS, and ICD-10 codes with conflicting, missing, or unclear information by consulting with provider’s staff. Maintain positive relationships with provider offices.
  • Determine the eligibility of the member and resolve questionable eligibility with Administration department, as appropriate.
  • Transmit correspondence or medical records by mail, e-mail, or fax.
  • Assess network status of requested providers. If non-network, determine if alternate network providers are available to provide same service. Communicate non-network status to requesting provider and ensure member is aware of same.
  • Protect the security of medical records to ensure that confidentiality is maintained.
Operational Support
  • Work with Claims, Customer Service, Provider Maintenance and Contracting staff to provide complete information necessary for clinical review.
  • Complete letter of agreement (LOA) requests for medically necessary services as needed. Follow up with Contracting Department for results on negotiations.
  • Ensure providers and members are notified and document when out of network services have been requested.
  • Operate the telephone queue according to department benchmarks and break schedules.
  • Maintain professional telephone etiquette demonstrating patience and willingness to assist callers.
  • Maintain records of all patient related phone conversations in the authorization system.
  • Scan, enter, and approve retrospective authorization requests and claims as directed by clinical staff.
  • Ensure retrospective claims are not duplicates by researching in claims system.
  • Utilize clinical staff for concerns and questions regarding processing of retrospective requests.
  • Adhere to desktop procedure for managing retrospective requests and get authorization for J-codes prior to processing.
  • Schedule meetings for participants with the HM team.
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, be self-accountable, create a positive impact, and be 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 represent those that an employee must meet to successfully perform this job’s essential functions. 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.

Benefits

Profit sharing, Health insurance
Refer code: 8443865. Western Growers Family Of Companies - The previous day - 2024-03-04 02:23

Western Growers Family Of Companies

Remote

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