Claims Analyst II

Menasha•Menasha, WI

9d•Hybrid

About The Position

Network Health is seeking a Claims Analyst II to examine and process paper and electronic claims. The role determines whether claims should be returned, pended, denied, or paid in accordance with established policies and procedures. It processes professional and facility claims, resolves claims and related issues, and helps ensure accurate and efficient claims processing while maintaining confidentiality. The position may be performed from a home office, the Brookfield or Menasha office, or through a combination of home and office work. Candidates must reside in Wisconsin, and reliable internet is required for home-office work. The schedule is 40 hours per week, Monday through Friday, between 8 a.m. and 5 p.m. The target start date is November 30, 2026, subject to the candidate’s availability.

Requirements

2–4 years of claims-processing experience.
Knowledge of current procedural terminology (CPT) and ICD-9 and ICD-10.
Knowledge of medical terminology, COB processing, and subrogation.
Candidates must reside in Wisconsin.
Reliable internet is required for home-office work.

Nice To Haves

High school diploma or equivalent preferred.
Past experience using QNXT Claims Workflow is a plus.
Prior experience with ACA, Medicaid, or similar health plans preferred.
Coding experience preferred.

Responsibilities

Adjudicate claims according to departmental policies, operating memos, corporate guidelines, members’ Certificates of Coverage, medical policies and procedures, and plan benefit interpretations.
Resolve claims and related issues in compliance with policy provisions.
Compare claim applications and provider statements with policy files and other records to verify completeness and validity.
Review claims for proper billing standards and completeness; obtain additional information from appropriate people or agencies as needed.
Process payments for approved claims and review home-office claims for payment up to $18,000.
Maintain department quality standards and established claims-processing turnaround times, and meet or improve individual production standards.
Identify potential coordination of benefits (COB), Workers’ Compensation, and subrogation issues and adjudicate claims accordingly.
Investigate and resolve pending claims within established time frames; identify claims to pend or suspend, review pending claims timely, and deny claims when the established time frame is reached without resolution.
Monitor the computerized claims-processing system for errors and make corrections or adjustments as needed.
Keep current on group-contract specifics, provider discounts, percentages and per diems, enrollee certificates and agreements, authorizations, and utilization-management policies.
Review claims for repricing, enter eligible claim data into the appropriate WRAP network repricing website, and override allowed amounts to apply internal or external discounts.
Document claim attributes and memos with pertinent payment information.
Process specialty claims, including transplant, URN, and COB claims, to determine appropriate pricing according to external contracts.
Perform other duties and responsibilities as assigned.