Associate Claims Representative

This is a fully remote position, open to applicants in Wisconsin.

📋 Description

• Process health insurance claims submitted by providers and members, either via paper or electronically.

• Release health insurance claims for payment in accordance with established workflows.

• Validate claims by utilizing knowledge of health insurance cost-sharing, limitations, and exclusions.

• Review claims to ensure completeness and accuracy.

• Apply medical necessity and/or eligibility guidelines to assess coverage.

• Work on assigned pend and error reports.

• Determine benefit levels based on summary plan language.

• Prepare requests for additional information when necessary.

• Address information requests from other departments within Sanford Health Plan.

• Refer complex claims to Senior and/or Lead Claims Representatives.

• Monitor maximum out-of-pocket expenses using accumulators.

• Carry out other assigned duties.

⛳️ Requirements

• A high school diploma or equivalent is required.

• At least one year of relevant experience is necessary.

• Proficient computer skills are essential.

• Ability to uphold confidentiality is required.

• Basic knowledge of Microsoft Office applications is needed.

• Strong analytical skills and meticulous attention to detail with a high degree of accuracy are important.

• Some college-level coursework is preferred.

• A minimum of one year of experience in medical claims processing is preferred.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and career advancement.

• Supportive work environment with a focus on teamwork and collaboration.