Claims Examiner I

Position Overview

Western Growers Health—a part of Western Growers Family of Companies—provides employer-sponsored health benefit plans for the agriculture industry. Our mission is to deliver value to employers by offering robust health plans that meet the needs of a diverse workforce. As a member of our team, you will help deliver quality health benefits and excellent customer service, making a real difference in the health care industry.

The Claims Examiner I reports to the Supervisor of Claims and is responsible for reviewing, processing, and adjudicating medical, dental, vision, and electronic claims in compliance with regulatory requirements and internal guidelines.

Key Responsibilities

• Adjudicate various claims (Dental, Vision, Medical, inpatient/outpatient, physician, HIPD, lab/radiology, accident, and TPL) based on Summary Plan Descriptions (SPD) and established guidelines.
• Analyze patient and medical information to identify discrepancies, verify pricing, confirm prior authorizations, and process claims accurately.
• Examine claim files for accuracy by verifying eligibility and requisite documentation, and contact Health Care Providers as needed.
• Resolve benefit and eligibility issues in line with company and ERISA guidelines, including processing low-level claims and re-pricing corrections.
• Maintain a HIPAA-compliant workstation to protect all confidential and sensitive data.
• Collaborate with internal teams and document processes, ensuring compliance with local, State, and Federal regulations.
• Utilize sound judgment and problem-solving skills to resolve issues and make timely decisions.
• Perform other duties as assigned to support member competitiveness and profitability.

Required Qualifications

• High school education or equivalent with 1 to 3 years of experience as a Health Claims Examiner or in a comparable role.
• Minimum of one year experience specifically handling medical, dental, vision, subrogation, and accident claims.
• Ability to interpret Plan Documents or Summary Plan Descriptions for accurate claim adjudication.
• Basic knowledge of medical terminology and familiarity with UB-04, HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
• Excellent verbal and written communication skills.
• Proficiency in 10-key data entry (40 WPM) and Microsoft Office applications, with the aptitude to learn new systems quickly.
• Ability to work under pressure and adapt to a changing environment.
• Working knowledge of ERISA claims processing and adjudication guidelines.

Benefits & Perks

• Compensation: $34,095 - $47,271
• Rich benefits package including profit-sharing
• Remote work opportunity – position is open to candidates residing anywhere in the U.S.