Claims Analyst II

Menasha•Menasha, WI

5d•Hybrid

About The Position

Network Health is seeking a Claims Analyst II to examine and process paper and electronic claims. In this role, you will determine whether to return, pend, deny, or pay claims in accordance with established policies and procedures. This position plays a vital role in ensuring accurate and efficient claims processing, contributing to the overall success of Network Health. 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 8am-5pm Monday through Friday. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood.

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.

Nice To Haves

Past experience using QNXT™ Claims Workflow a plus
Prior experience with ACA, Medicaid, or similar health plans preferred.
Coding experience preferred.

Responsibilities

Processes 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.
Reviews claims to ensure compliance with proper billing standards and completeness of information.
Obtains additional information from appropriate person and/or agency as needed.
Maintains department quality standards.
Maintains established department turn-around processing time.
Maintain and/or improves individual production rate standards and department quality standards.
Identifies potential coordination of benefits (COB), Workers Compensation, and Subrogation issues and adjudicates claims accordingly.
Investigates and resolves pending claims in accordance with established time frames.
Identifies claims needing to be pended or suspended.
Reviews pending claims timely and denies claims after established time frame is reached without resolution.
Monitors computerized system for claims processing errors and make corrections and/or adjustments as needed.
Keeps current on group contracts specifics, provider discounts, percentages and per diems, enrollee certificates and agreements, authorizations and other utilization management policies, etc.
Reviews home office claims for payment up to $18,000.00.
Reviews claims for re-pricing.
Enters eligible claim data into appropriate WRAP network re-pricing website.
Overrides claims allowed amounts to apply internal/external discounts.
Appropriately documents attributes and memos for pertinent information related to claims payment.
Processes specialty claims (transplant, URN, COB) to determine appropriate pricing according to external contract.
Performs other duties and responsibilities as assigned.