Plan Coder

Position reports to the Supervisor Benefit Distribution & Installation and performs in-depth pharmacy and medical plan coding of new and existing business accounts. This position ensures that all new and existing health (medical, dental, pharmacy) insurance plans underwritten by Western Growers Assurance Trust (WGAT) and those of Pinnacle Claims Management, Inc. (PCMI) are in compliance with the respective employers’ summary plan descriptions.

Plan Coding

• Plan code new business and plan changes.
• Verify new and existing plans loaded on the company’s claim management system against the appropriate Summary Plan Description to determine the accuracy of present and future claims payments.
• Respond to work orders received from examiners to investigate plan issues and irregularities.
• Evaluate testing requests for all new plans prior to loading them into the production system.

Administrative

• Keep a detailed log of open and completed work.
• Document resolutions to closed work orders.
• Identify inefficiencies within established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
• Create and document a minimum of one new Standard Operating Procedure (SOP) annually.
• Identify, initiate, and implement at least one process improvement and/or innovation annually.
• Maintain a detailed log of plans currently being coded and in the process of being loaded.
• Send confirmations to internal stakeholders when applicable plans have been loaded.
• Work with programmers to test claims and related system programs to verify impact within the Health Care Processing System (HCPS).

Other

• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and use appropriate security techniques to protect confidential and protected client data.
• Maintain and service safety equipment such as smoke detectors, fire extinguishers, and first aid kits.
• Perform all other duties as assigned.

Physical Demands / Work Environment

The employee is regularly required to communicate with others, frequently move around the office, and often use tools, objects, and controls. The noise level in the work environment is usually moderate.