Claims Analyst II

About the role

Network Health’s success is rooted in its mission to create healthy and strong Wisconsin communities. This mission drives the decisions we make, including the people we choose to join our growing team.

Responsibilities

• Adjudicate claims by following departmental policies, operating memos, and corporate guidelines.
• Resolve claims and related issues in compliance with policy provisions.
• Compare claims applications and provider statements with policy files and other records to ensure completeness and validity.
• Process payments for claims that are approved.
• Process Professional and Facility claims for payment in accordance with members’ Certificate of Coverage, established medical policies and procedures, and plan benefit interpretation while maintaining a high level of confidentiality.
• Review claims to ensure compliance with proper billing standards and completeness of information.
• Obtain additional information from appropriate person and/or agency as needed.
• Maintain department quality standards and established turn-around processing time.
• Maintain and/or improve individual production rate standards and department quality standards.
• Identify potential coordination of benefits (COB), Workers Compensation, and Subrogation issues and adjudicate claims accordingly.
• Investigate and resolve pending claims in accordance with established time frames; identify claims needing to be pended or suspended.
• Review pending claims timely and deny claims after established time frame is reached without resolution.
• Monitor computerized system for claims processing errors and make corrections and/or adjustments as needed.
• Keep current on group contracts specifics, provider discounts, percentages and per diems, enrollee certificates and agreements, authorizations and other utilization management policies, etc.
• Review home office claims for payment up to $18,000.00.
• Review claims for re-pricing; enter eligible claim data into appropriate WRAP network re-pricing website and override claims allowed amounts to apply internal/external discounts.
• Appropriately document attributes and memos for pertinent information related to claims payment.
• Process specialty claims (transplant, URN, COB) to determine appropriate pricing according to external contract.
• Perform other duties and responsibilities as assigned.

Requirements

• High school diploma or equivalent preferred.
• 2–4 years claims processing experience required.
• Knowledge of current procedural terminology (CPT) and international classification of diseases (ICD-9 and ICD-10).
• Medical terminology, COB processing, subrogation.
• Past experience using QNXT™ Claims Workflow a plus.
• Prior experience with ACA, Medicaid, or similar health plans preferred.
• Coding experience preferred.

Location and Schedule

Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required), at our office in Brookfield or Menasha, or a combination of both in our hybrid workplace model. Hours: 1.0 FTE, 40 hours per week between 8 am–5 pm Monday through Friday.