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Director of Medical Claims Operations  (Management & Business)
Irvine, CA 92618
Recruited by: Pamela Flores | Recruiter | Western Growers Association See all my Jobs

  • Hiring Company: Western Growers
  • Industry: Management & Business
  • Compensation: to be determined
  • Expires: Feb 10, 17
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Job Description

Headquarters located in Irvine, CA, Western Growers is a multi-faceted service organization and trade association founded in 1926 that operates a number of companies that offer a wide array of products and services to our member companies and other customers.

We operate as a large health benefit insurer (Western Growers Assurance Trust), a Third Party Administrator (Pinnacle Claims Management), a Pharmacy Benefit Manager (Pinnacle RX Solutions), an Insurance Brokerage which represents both Health and Commercial lines (Western Insurance Services), and finally a Financial Services company (Western Growers Financial Services). Visit all of the companies at www.wga.com. Watch this to learn more http://youtu.be/UcP79T2tRxQ

As a Director of Claims Operations you will plan and direct all aspects of Western Growers Assurance Trust’s (WGAT) and Pinnacle Claims Management (PCMI) claim operations functions. You will be responsible for the development of procedures and policies to enhance and improve the processing of claims and the management of customer service and reinsurance. In addition, leads and directs the work of the manager of claims, supervisor of customer service and claims training manager.

What you get to do:
• Responsible for claims being processed; production and quality.
• Develop and monitor in-house continuing education programs for staff.
• Responsible for customer service call center performance within industry standards, organizational standards and contractual standards with clients and third party vendors.
• Revise procedures to improve efficiency of work flow of Claims, Reinsurance, Clerical, Customer Service and Utilization Review departments.
• Prepare annual budgets and review monthly expenses for Claims, Customer Service, Implementation & Fulfillment, Audit & Recovery departments.
• Responsible for claims coordination with external vendor relationships in the area of Utilization Management, Case Management and clearing house vendors to ensure performance within industry standards as required by the benefit plan contracts under WGAT and PCMI.
• Directs the review of complex high dollar claims
• Approve personnel activity concerning hiring, training/development, and evaluation of staff performance.
• Prepare and present claims and customer service statistical & quality reports to the Trustees.
• Makes routine visits to the field to visit customers and accounts.

Essentials to have:
• Bachelors’ degree (BA/BS) and/or 10 plus years’ experience in supervising/managing a health care claims operation preferred.
• Exceptional ability to communicate both verbally and in writing.
• Professional certification from HIAA, LOMA, or other similar industry-specific continuing education programs preferred.
• Experience working with and/or managing a fraud investigative unit
• Proficient in end user programs e.g. spreadsheet, word processing, presentation, email

We offer an extensive benefits package which includes competitive salaries, a wide selection of health benefits, vacation & holiday pay, excellent 401K which includes company matching up to 3% and profit sharing which is trending at 7%, education reimbursement program, on-site auto detailing and dry cleaning service and much more!