Associate Claims Representative

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

📋 Description

• Process health insurance claims received from providers and members through both paper and electronic submissions.

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

• Validate claims by assessing health insurance cost sharing, limitations, and exclusions.

• Review claims to ensure completeness and accuracy.

• Apply medical necessity and eligibility guidelines to assess coverage.

• Address assigned pend and error reports.

• Determine benefit levels based on summary plan language.

• Prepare requests for additional information as necessary.

• Respond to information requests from other departments within Sanford Health Plan.

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

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

• Perform additional duties as assigned.

⛳️ Requirements

• High school diploma or equivalent is required.

• Some college-level coursework is preferred.

• A minimum of one year of relevant experience is required.

• At least one year of medical claims processing experience is preferred.

• Strong analytical skills and a sharp attention to detail.

• High level of accuracy in work output.

• Proven computer literacy.

• A willingness to learn and persistence in completing tasks.

• Ability to maintain confidentiality.

• Basic knowledge of Microsoft Office is expected.

🏝️ Benefits

• Comprehensive health insurance coverage.

• Retirement savings plan with company matching.

• Opportunities for professional development and advancement.