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Claims Examiner I

April 29, 2026

<div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"><b>Western Growers Health─ </b>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. The unmatched benefit options provided by Western Growers Health stem from the core mission of Western Growers Association (est. 1926) to support the business interests of employers in the agriculture industry.<br><br>Our mission at Western Growers Health is to deliver value to employers by offering robust health plans that meet the needs of a diverse workforce. By working at Western Growers Health, you will join a dedicated team of employees who care about offering quality health benefits and excellent customer service to plan participants. If you want to start making a difference working in the health care industry, then apply to Western Growers Health today! </span></div><p><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"><b>Compensation: $40,580.28-$52,756.02 with a rich benefits package that includes profit-sharing.</b> </span></p><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"><b>JOB DESCRIPTION SUMMARY </b> </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">The Claims Examiner I reports to the Supervisor of Claims. Claims Examiner I is responsible for reviewing and processing medical, dental, vision, and electronic claims per state, federal, and health plan regulatory requirements and department guidelines, as well as meeting established quality and production performance benchmarks, including research and review of applicable documentation. The Claims Examiner I will thoroughly review, analyze, and research health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The position will assist in resolving issues from providers, customer service, member services, health plan, and other internal customers. </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"> </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"><b>QUALIFICATIONS </b> </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• High school education or equivalent: minimum three (3) to five (5) years of experience as a Health Claims Examiner or comparable industry experience preferred. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• A minimum of one (1) year experience as a Claims Examiner for medical, dental claims and vision, subrogation, and accident claims, highly desired. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Basic knowledge of medical terminology. Familiar with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Good verbal and written communication skills. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Proficient in 10-key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Ability to work under pressure and adapt to changing environment </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Home router with wired Ethernet (wireless connections and hotspots are not permitted). </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.) </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• A functioning smoke detector, fire extinguisher, and first aid kit on site.</span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"> </span></div><div style=""><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"><b>DUTIES AND RESPONSIBILITIES </b> </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"><i>Claims Processing & Quality Assurance </i> </span></div><div style="margin-bottom: 0.65pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe. </span></div><div style="margin-bottom: 0.65pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Analyze patient and medical records to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly. </span></div><div style="margin-bottom: 0.65pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Examine claim files for accuracy: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation. </span></div><div style="margin-bottom: 0.65pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Research through all vendor portals, including but not limited to Valenz, Occunet, Anthem </span></div><div style="margin-bottom: 0.65pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Resolve benefit and eligibility issues that require detailed knowledge, support for customers within the claims processing, Company and ERISA guidelines. Process low to medium level claims, re-pricing corrections. </span></div><div style="margin-bottom: 0.65pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Research, resolve and respond to all correspondence and internal communication (Ops Connect) related to electronic and paper claims as assigned. </span></div><div style="margin-bottom: 0.65pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data. </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Meet and maintain individual and department productivity and quality standards. </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"> </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"><i>Problem Solving, Judgement & Compliance </i> </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Examine a problem, set of data or text and consider multiple sides of an issue, weighs consequences before making a final decision. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Ensure compliance with all appropriate policies and practices, local, State, Federal regulations and requirements regarding claims and contract administration. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Partner with peers to document and analyze functional requirements, identify gaps and alternative approaches to resolve problems. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Contribute to defining and documenting standards and periodically reviewing them to integrate appropriate industry standards. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Alert supervisors to potential higher risk compliance issues </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Make timely and effective decisions based on available information </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Recognize issues, analyzes, solves problems, researches, identifies trends and determines actions needed to advance the decision-making process within a realistic timeframe. Follows up as necessary. </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Involve the appropriate people in defining, understanding the impact and resolving problems. </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"> </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"><i>Other </i> </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• 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. </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Maintain internet speed of 40MB download and 10MB upload and router with wired Ethernet. </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"> • Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data. </span></div><div style="margin-bottom: 0.75pt;"><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• Maintain and service safety equipment (e.g. smoke detector, fire extinguisher, first aid kit). </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">• All other duties as assigned. </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"> </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;"><b>PHYSICAL DEMANDS/WORK ENVIRONMENT </b> </span></div><div><span style="font-family: 'times new roman' , times;font-size: 12.0pt;">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. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.</span></div>

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...