Claims Analyst

TEKsystems•Menasha, WI

2d•$19 - $19•Remote

About The Position

We are seeking a detail-oriented Claims Analyst II to examine, adjudicate, and process professional and facility medical claims in accordance with established policies, procedures, and regulatory requirements. This role is responsible for ensuring accurate, timely, and compliant claims processing while maintaining confidentiality and quality standards. The Claims Analyst II plays a critical role in resolving complex claims issues, identifying coordination of benefits (COB) and subrogation opportunities, and ensuring claims are processed in alignment with member benefits, provider contracts, and internal guidelines.

Requirements

High school diploma or equivalent (preferred)
2–4 years of medical claims processing experience required
Working knowledge of: Current Procedural Terminology (CPT) ICD-9 and ICD-10 diagnosis codes Medical terminology Coordination of Benefits (COB) Subrogation processes
Strong attention to detail with the ability to interpret benefits and contracts accurately
Ability to manage multiple priorities while meeting productivity and quality standards
Proficiency with claims processing systems; QNXT™ Claims Workflow experience a plus

Nice To Haves

Prior experience with ACA, Medicaid, or similar health plans preferred
Medical coding experience preferred

Responsibilities

Examine and adjudicate paper and electronic professional and facility claims by determining whether claims should be paid, denied, pended, or returned in accordance with: Member Certificates of Coverage Medical policies and procedures Corporate guidelines and operating memos
Process approved claims accurately and timely, including payments up to $18,000 in accordance with authority levels.
Ensure claims comply with proper billing standards, coding requirements, and completeness of documentation.
Review claims for re-pricing and apply internal or external discounts, provider contracts, per diems, and fee schedules as appropriate.
Enter eligible claims into WRAP network re-pricing systems and override allowed amounts when necessary.
Investigate and resolve pending claims within established timeframes.
Identify claims requiring pended or suspended status and follow up to resolution.
Deny claims appropriately when required information is not received within established guidelines.
Obtain additional information from providers, members, employers, or external agencies as needed.
Resolve claims and related issues in compliance with policy provisions and regulatory standards.
Identify and adjudicate claims involving: Coordination of Benefits (COB) Workers’ Compensation Subrogation Specialty claims including Transplant, URN, and COB pricing
Apply appropriate pricing methodologies based on external contracts and benefit interpretation.
Monitor claims processing systems for errors and make necessary corrections or adjustments.
Maintain current knowledge of: Group contracts and enrollee certificates Provider agreements and discounts Authorizations and utilization management policies Medical coding updates and regulatory changes
Maintain departmental quality standards and established turnaround time requirements.
Meet or exceed individual productivity and accuracy benchmarks.
Appropriately document claim attributes, notes, and memos to support claim determinations and audits.
Protect confidential and sensitive member and provider information in accordance with HIPAA and company policies.
Collaborate with team members, supervisors, and other departments to resolve escalated or complex claims issues.
Participate in training and ongoing education to remain current with systems, policies, and procedures.
Perform other duties and responsibilities as assigned.