Remote -Must Live In WI-Claims Analyst

TEKsystems • Milwaukee, WI

4d • $19 - $19 • Remote

About The Position

We are seeking a Claims Analyst II to examine and process paper and electronic claims. The analyst determines whether claims should be returned, pended, denied, or paid in accordance with established policies and procedures. This role processes professional and facility claims according to members’ Certificates of Coverage, medical policies and procedures, and plan benefit interpretation while maintaining confidentiality. The position is fully remote and requires the employee to live in Wisconsin.

Requirements

• 2–4 years of medical claims processing experience.
• Knowledge of current procedural terminology (CPT) and international classification of diseases (ICD-9 and ICD-10).
• Knowledge of medical terminology, coordination of benefits processing, and subrogation.

Nice To Haves

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

Responsibilities

• Adjudicate claims according to departmental policies, operating memos, corporate guidelines, and policy provisions.
• Compare claim applications and provider statements with policy files and other records to verify completeness and validity.
• Process approved claim payments and review home office claims for payment up to $18,000.
• Review claims for compliance with billing standards and completeness; obtain additional information from appropriate people or agencies when needed.
• Maintain department quality standards, processing turnaround times, and individual production-rate standards.
• Identify potential coordination of benefits, Workers Compensation, and subrogation issues and adjudicate claims accordingly.
• Investigate and resolve pending claims within established time frames; identify claims to pend or suspend, and deny claims when the established resolution time frame has passed.
• Monitor the computerized claims system for processing 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 relevant attributes and memos related to claims payment.
• Process specialty claims, including transplant, URN, and COB claims, to determine appropriate pricing according to external contracts.
• Perform other duties and responsibilities as assigned.

Benefits

• Medical, dental, and vision coverage, subject to eligibility.
• Critical illness, accident, and hospital coverage, subject to eligibility.
• 401(k) retirement plan with pre-tax and Roth post-tax contributions available, subject to eligibility.
• Voluntary life and AD&D insurance for the employee and dependents, subject to eligibility.
• Short- and long-term disability coverage, subject to eligibility.
• Health Spending Account (HSA), subject to eligibility.
• Transportation benefits, subject to eligibility.
• Employee Assistance Program, subject to eligibility.
• Time off/leave, including PTO, vacation, or sick leave, subject to eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED