Compliance Auditor

At Pinnacle Claims Management, an innovative third‑party administrator (TPA), we provide 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 are committed to supporting employees with competitive compensation, flexible work arrangements, and personal development. Compensation: $45,091 – $63,617 with a rich benefits package that includes profit‑sharing. Job Description Summary Position reports to the Supervisor, Benefit Installation & Distribution and performs in‑depth plan coding and testing of new and existing business accounts. This position ensures that all new and existing health (medical/dental) insurance plans underwritten by the Western Growers Assurance Trust (WGAT) and those of Pinnacle, Inc. (PCMI) are in compliance with the respective employers’ summary plan descriptions. Qualifications BS/BA degree in Business or related field and 3‑5 years of recent experience as a medical/dental claims auditor or plan testing. Exceptional understanding and ability to interpret summary plan descriptions of employee medical/dental benefits. Strong ability to work efficiently in a multi‑task, multi‑project, and multi‑demanding environment to meet goals, dates, and milestones. Ability to anticipate problems, recommend solutions, and exercise best judgement. Excellent writing, editing, and proofreading skills. Proficient ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts. Experience 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; familiarity with ICD‑10, CPT, HCPCS, and CDT codes. Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds; home router with wired Ethernet. Designated room or steps taken to protect company information. Working smoke detector, fire extinguisher, and first aid kit on site. Duties and Responsibilities Testing Using close and comprehensive analyses, verify new and existing plans loaded into the company’s claim management system against the appropriate Summary Plan Description to determine the accuracy of present and future claims payments. Test all new plans prior to loading them into production (medical, dental and vision plans). Work with programmers to test claims and related system programs to verify impact within the HCPS. Conduct system analysis and testing of mass system updates. Plan coding of 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 the 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 innovation. Other Utilize all capabilities to satisfy one mission— to enhance the competitiveness and profitability of our members. Act with curiosity, diligence, and a positive impact mindset. Maintain HIPAA‑compliant workstation and appropriate security techniques to protect confidential data. Maintain and service safety equipment (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. While performing the duties of this job, the employee is regularly required to communicate with others, move around the office, use tools, objects, and controls, and work in a moderate noise level environment. #J-18808-Ljbffr