Implementation Auditor

At Pinnacle Claims Management, an innovative third‑party administrator (TPA), we provide comprehensive and customized health benefits administration services for self‑funded companies, including health management, wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we prioritize the well‑being of our employees and offer flexible work arrangements such as work‑from‑home, in‑office, or hybrid options. Compensation: $45,091 - $63,617 with a rich benefits package that includes profit‑sharing. Job Description Summary This role reports to the Supervisor, Benefit Installation & Distribution and performs in‑depth plan coding and testing of new and existing business accounts. The position ensures that all health (medical/dental) insurance plans underwritten by the Western Growers Assurance Trust (WGAT) and Pinnacle, Inc. (PCMI) are compliant with their summary plan descriptions. Qualifications BS/BA degree in Business or related field and a minimum of 3–5 years of recent experience as a medical/dental claims auditor or plan testing experience, preferred. Exceptional understanding of summary plan descriptions for employee medical/dental benefits. Strong ability to work efficiently and effectively in a multi‑task, multi‑project environment to meet goals, dates, and milestones. Ability to anticipate problems, recommend solutions, and exercise best judgement. Excellent writing, editing, and proofreading skills for correspondence, reports, and other materials. Proficient analytical and interpretive skills for group health benefits provisions, administrative policies, and provider contracts. Experience with conducting research and presenting complex information. Excellent communication and interpersonal skills. Superior organization skills and high attention to detail. Ability to learn complex business processes and apply knowledge to make informed decisions. Advanced skills in Microsoft Office applications. Knowledge of medical terminology and familiarity with ICD‑10, CPT, HCPCS, and CDT codes. Required home office setup: wired Ethernet router, designated room for work, functioning smoke detector, fire extinguisher, and first aid kit. Duties and Responsibilities Testing Use comprehensive analyses to verify new and existing plans loaded on the company’s claims management system against the appropriate summary plan descriptions to determine the accuracy of future claims payments. Test all new plans prior to loading them in production (medical, dental, and vision plans). Collaborate with programmers to test claims and related system programs to verify impact within the HCPS. Conduct system analysis and testing of mass system updates. Perform plan coding for new business and plan changes for medical, dental, and vision plans. Communicate with other operational departments to ensure smooth integration of new plans for both WGAT and PCMI moving into production. Reporting Provide monthly reporting of all requested plan issues submitted from the Claims department. Identify inefficiencies within established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses. Create and document Standard Operating Procedures (SOP). Identify, initiate, and implement process improvements and/or innovations. Other Utilize all capabilities to enhance the competitiveness and profitability of our members. Strive to understand what others are trying to achieve, plan, and execute work helpfully and collaboratively. 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 perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee is regularly required to communicate with others, move around the office, and use tools and controls. The noise level in the work environment is usually moderate. #J-18808-Ljbffr