Claims Analyst

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

📋 Description

• Review and manage both paper and electronic claims.

• Assess claims to decide if they should be returned, pended, denied, or paid based on established policies and procedures.

• Evaluate claims in accordance with departmental policies, operational memos, and corporate guidelines.

• Address claims and associated issues while adhering to policy provisions.

• Verify claims applications and provider statements against policy files and other records for accuracy and completeness.

• Process payments for claims that have been approved.

• Handle Professional and Facility claims as per coverage certificates, medical policies, procedures, and interpretations of plan benefits.

• Examine claims for adherence to billing standards and completeness.

• Acquire additional information from relevant individuals or agencies as needed.

• Uphold departmental quality standards and processing turnaround times.

• Identify and resolve coordination of benefits (COB), Workers Compensation, and Subrogation matters.

• Investigate and settle pending claims within specified time limits.

• Supervise computerized claims-processing systems for errors, making necessary corrections or adjustments.

• Stay updated on group contracts, provider discounts, percentages, per diems, enrollee certificates, agreements, authorizations, and utilization management policies.

• Review home office claims for payments up to $18,000.00.

• Assess claims for repricing and input eligible claim data into the WRAP network repricing website.

• Override approved amounts to apply either internal or external discounts.

• Record relevant claims-payment characteristics and memos.

• Process specialty claims, such as transplant, URN, and COB, according to external contract pricing.

• Carry out other assigned tasks.

⛳️ Requirements

• High school diploma or equivalent is preferred.

• 2-4 years of experience in medical claims processing is required.

• Familiarity with current procedural terminology (CPT) is necessary.

• Understanding of the international classification of diseases (ICD-9 and ICD-10) is essential.

• Knowledge of medical terminology is required.

• Awareness of COB processing is necessary.

• Understanding of subrogation is required.

• Previous experience using QNXT Claims Workflow is advantageous.

• Prior experience with ACA, Medicaid, or similar health plans is preferred.

• Coding experience is preferred.

🏝️ Benefits

• Medical, dental & vision coverage.

• Critical Illness, Accident, and Hospital insurance.

• 401(k) Retirement Plan with pre-tax and Roth post-tax contributions.

• Life Insurance (Voluntary Life & AD&D for the employee and dependents).

• Short and long-term disability coverage.

• Health Spending Account (HSA).

• Transportation benefits.

• Employee Assistance Program.

• Time Off/Leave (PTO, Vacation, or Sick Leave).