Claims Analyst II

Network Health WI•Menasha, WI

10d•Hybrid

About The Position

Network Health is seeking an entry-level Claims Analyst II to examine and process paper and electronic claims. The analyst determines whether claims should be returned, pended, denied, or paid according to established policies and procedures. This role processes professional and facility claims, reviews them for accuracy and completeness, resolves issues, and processes payments for approved claims while maintaining confidentiality and departmental quality and turnaround standards. The position may be performed from a home office by candidates residing in Wisconsin, at the Brookfield or Menasha office, or through a combination of home and office under the hybrid workplace model. Reliable internet is required for home-office work. The schedule is 40 hours per week, Monday through Friday, between 8:00 a.m. and 5:00 p.m. The target start date is November 30, 2026, contingent on the candidate’s availability. Network Health also offers employees the opportunity to volunteer in their local neighborhoods while being paid.

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.
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, and corporate guidelines.
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.
Process payments for approved claims.
Process professional and facility claims in accordance with members’ Certificates of Coverage, medical policies and procedures, and plan benefit interpretations while maintaining confidentiality.
Review claims for compliance with billing standards and completeness of information.
Obtain additional information from appropriate people or agencies as needed.
Maintain department quality standards and established processing turnaround times, and maintain 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 promptly, and deny claims when the established time frame is reached without resolution.
Monitor the computerized claims system for processing errors and make corrections or adjustments as needed.
Stay current on group contract details, provider discounts, percentages and per diems, enrollee certificates and agreements, authorizations, and utilization management policies.
Review home-office claims for payment up to $18,000.
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.