Join our team of dedicated professionals who are committed to ensuring our clients can provide affordable health benefit solutions for their employees.

Part of the Western Growers Family of Companies, Pinnacle Claims Management is a 3rd party administrator that provides health benefits administration and related services to companies that self-fund their insurance. We are also a contracted partner with Covered California for Small Business.

Pinnacle is independently owned and has been serving clients for 20+ years. We are also part of the Western Growers Family of Companies.

For more details on open positions, visit our careers page!



Compensation:$48,012- $67,416 with a rich benefits package that includes profit-sharing.

Job Description Summary

This position reports to the Supervisor I, Administration and assists with the daily operations of the Eligibility and Financial Specialist team. This role will provide support in the planning, training, auditing and evaluation of workflows. This position will coordinate work activities to achieve production and quality standards as well as recognizing and recommending process improvements.

Qualifications

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  BA/BS degree in accounting, finance, or business related field preferred, plus two (2) years of Accounting/Business experience with knowledge of generally accepted accounting procedures, analytical abilities or equivalent combination of education and experience.
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  Three (3) years’ experience in an Eligibility Specialist and/or Financial Specialist role.
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  Advanced skills in establishing priorities, multi-tasking, time management, and work independently with minimal supervision.
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  Ability to lead, train and coach others Example: train temporary staff during peak, train and develop eligibility team with new process and procedures.
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  Knowledge of generally accepted Health Care Eligibility and Billing procedures as well as Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), California-COBRA, Multiple Employer Welfare Arrangement (MEWA), Patient Protection and Affordable Care Act (PPACA) and Employee Retirement Income Security Act (ERISA) legislation.
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  Advanced computer experience with Microsoft Office Suite: Word, Excel, Visio, Power Point, and Outlook.
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  Knowledge of processing electronic data interchange (EDI) file updates in a legacy system environment. Intermediate knowledge of Excel spreadsheet manipulation to produce audit files and reports.
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  Excellent written and oral communication skills to include modern business communications, formatting of professional letters, email, reports and phone etiquette.
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  Ability to work overtime as needed.
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  Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. up to 10% of the time.

Duties And Responsibilities

Process Management & Maintenance

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  Oversee day-to-day production and workflow.
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  Make adjustments and reassign duties as necessary to maintain effective unit production.
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  Train Administration team in daily production methods. Identify and resolve training deficiencies on an as-needed basis.
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  Assist staff in completing difficult research or analysis to resolve discrepancies on an as-needed basis.
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  Research and resolve technical issues and/or client problems as they arise with minimal direction.
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  Develop and maintain unit production reports. Use report data to make workflow enhancements to increase productivity and quality.
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  Monitor metrics to ensure daily goals are met. Example: Access to cares cases processed within 24 hours, Team is processing 30 cases per day, and audit goal of 95% is met by team
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  Produce electronic spreadsheets and/or reports for audit and processing purposes.
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  Create and document department policies and procedures, as required.
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  Review manual and/or EDI enrollment transactions (add, change, terminate) in health care processing system as received from the client or internal sources in accordance to Participation Agreements, Employer Policy Statement, Eligibility Guidelines and/or Summary Plan Descriptions.
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  Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
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  Create and document a minimum of one new Standard Operating Procedure (SOP) annually.
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  Identify, initiate and implement at least one process improvement and/or innovation annually.

Customer Service

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  Act as liaison with other departments for solutions of issues.
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  Interface effectively with internal departments and external vendors, brokers or other business contacts to coordinate interrelated activities and to resolve eligibility and/or billing issues as they arise.
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  Provide timely and effective customer service to clients for requests, inquiries or issues concerning enrollment and/or billing items on their account.
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  Meet processing cycle time standards and production due dates as set forth by management.
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  Maintain a HIPAA compliant workstation and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
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  Serve as representative of Western Growers Assurance Trust (WGAT) / Pinnacle Claims Management Inc. (PCMI) displaying professionalism, knowledge, customer service and discretion in all interactions with other members of the WGAT/PCMI community and their customers.

Training and Mentoring

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  Train Administration team in daily production methods.
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  Identify and resolve training deficiencies on an as-needed basis.
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  Motivate employee performances by providing recognition for a job well done or constructive feedback when needed.
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  Provide one-on-one coaching for internal and external customers.
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  As the subject matter expert, support and maintain effective working relationships with a variety of stakeholders and serve as the point of contact to the teams.

Other

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  Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
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  Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 10% of the time.
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  All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here represent those that an employee must meet to perform this job’s essential functions 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. The employee frequently is required to travel to both indoor and outdoor areas that can vary in exposure and temperature. The employee is frequently required to operate a motor vehicle, use objects, tools, or controls, and/or required to lift up to 50lbs. The noise level in the work environment is usually moderate.