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Operations Specialist II
Operations Specialist IIPinnacle Claims Management • Irvine, CA, US
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Operations Specialist II

Operations Specialist II

Pinnacle Claims Management • Irvine, CA, US
14 hours ago
Job type
  • Full-time
Job description

Overview

Western Growers Health, a part of Western Growers Family of Companies, provides employer-sponsored health benefit plans to meet the needs of those working for the agriculture industry. Our mission is to deliver value to employers by offering robust health plans and excellent customer service to plan participants. Compensation : $45,091 - $63,617 with a rich benefits package that includes profit-sharing.

Job Description

This position reports to the System Operations Manager, Key Accounts and serves as a critical operational resource responsible for adjudicating complex claims, analyzing claim payment accuracy, performing root cause analysis on claim deficiencies, and supporting leadership in continuous quality improvement. This role manages claims and financial workflows across the enterprise Flexible Spending Accounts (FSA), Health Reimbursement Account (HRA), and Health Savings Account (HAS) portfolios exclusively for WEX clients. The incumbent will support claims quality assurance, evaluate payment integrity programs, financial reporting, client account management, and operational process improvements. The incumbent will support leadership through proactive analysis of claims trends, development of corrective actions, and implementation of reporting solutions to ensure operational excellence.

Qualifications

  • BA / BS degree in accounting, finance or business-related field preferred plus a minimum of three (3) to four (4) years of experience in healthcare claims adjudication, financial account maintenance, or claims operations in a Third-Party Administrator (TPA), health plan, or healthcare financial services environment, preferred.
  • Strong understanding of medical, dental, vision, and reimbursement claims processing; familiarity with FSA / HRA / HSA administration.
  • Skills to establish priorities, multi-task, work under pressure and deadlines, work independently with minimal supervision or in team environment.
  • Intermediate knowledge of end-user office software (calendar, word-processing, spreadsheet and email) and the ability to develop strong proficiency working with a proprietary Health Care system.
  • Excellent written and oral communications skills, to include modern business communications, formatting professional letters, reports and phone etiquette.
  • Customer service oriented.
  • Ability to analyze and resolve technical problems and / or client inquiries as they arise.
  • Knowledge of health insurance industry and standard healthcare eligibility provisions.
  • Ability to work independently and collaboratively in a remote environment.
  • Ability to work overtime as requested by management and based upon department needs and compliance.
  • 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.
  • A functioning smoke detector, fire extinguisher, and first-aid kit on site.

Responsibilities

  • Adjudicate all claim types (medical, dental, vision, reimbursement) in accordance with Plan Documents, Standard Plan Design (SPD), and internal Standard Operating Procedures (SOP) in the company's internal claims and financial processing system.
  • Review and resolve claims requiring customer follow-up, benefit clarification, or cross-departmental collaboration.
  • Evaluate payment integrity programs through data reporting, proactively identify anomalies, and recommend corrective actions.
  • Assist with investigation and remediation of claim errors identified through quality control audits or leadership requests.

    • Financial Reporting & Account Maintenance

  • Maintain / manage all PCMI contributions / premium reimbursements, FSA / HRA / HSA reimbursements.
  • Manage the process of funding and releasing self-funded claims payments.
  • Analyze and resolve claims-related account discrepancies, including the application of refunds, adjustments, and ledger maintenance. Maintain FSA, HSA, and HRA programs.

    • Process Management & Customer Service

  • Verify / authorize refunds for terminations and overpayments on all accounts.
  • Participate in cross-functional initiatives to improve claims and financial processing efficiency.
  • Identify process gaps or inefficiencies and recommend improvements to systems, workflows, or reporting tools.
  • Process related written and verbal account inquiries to a conclusion in a timely manner, including required research.
  • Identify inefficiencies within established processes and suggest solutions to save time, reduce risk, and / or reduce expenses.
  • Create and document Standard Operating Procedures (SOPs).
  • Identify, initiate and implement process improvements and / or innovation.
  • Serve as a subject matter expert and escalation point for complex claim adjudication, financial inquiries, and operational process questions for WEX clients and Account Management team.
  • Work collaboratively with internal teams (Eligibility, Customer Service, IT) to resolve account issues and support a high standard of client service.
  • Partner with leadership to prepare and present operational updates and claim performance reports for internal and external stakeholders.

    • Other

  • Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of confidential / protected client 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. The employee is regularly required to communicate with others and to move around the office. The noise level in the work environment is usually moderate.

    Seniority level

  • Mid-Senior level

    • Employment type

  • Full-time

    • Job function

  • Management and Manufacturing

    • Industries

  • Hospitals and Health Care

    • J-18808-Ljbffr

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