Remote For WI Residents- Claims Analyst

TEKsystems•Milwaukee, WI

2d•$19 - $19•Remote

About The Position

We are 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. Key responsibilities of this position include the following: Adjudicate claims by following departmental policies, operating memos, and corporate guidelines. Resolve claims and related issues in compliance with policy provisions. Compare claims applications and provider statements with policy files and other records to ensure completeness and validity. Process payments for claims that are approved. Job 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.

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

Adjudicate claims by following departmental policies, operating memos, and corporate guidelines.
Resolve claims and related issues in compliance with policy provisions.
Compare claims applications and provider statements with policy files and other records to ensure completeness and validity.
Process payments for claims that are approved.
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.