Claims Processor

TEKsystems • Milwaukee, WI

7d • $19 - $19 • Remote

About The Position

The Claims Analyst II examines and processes paper and electronic claims, determining whether claims should be returned, pended, denied, or paid in accordance with established policies and procedures. The role processes professional and facility claims based on members’ Certificates of Coverage, medical policies, plan benefit interpretations, and applicable contracts while maintaining confidentiality.

The position reviews claim information for completeness, validity, and billing compliance; investigates pending claims and related issues; obtains additional information when needed; and processes approved payments. It also handles claims requiring coordination of benefits, workers’ compensation, subrogation, repricing, or specialty pricing. This is a contract-to-hire position based out of Milwaukee, Wisconsin, and is fully remote. The stated pay range is $19.25 per hour.

Requirements

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

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 check completeness and validity.
• Process payments for approved claims.
• Process professional and facility claims according to 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 meet or improve individual production 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, review them on time, and deny claims when the established resolution time frame is reached.
• Monitor the computerized claims-processing system for 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 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 attributes and memos pertinent to claims payment.
• Process specialty claims, including transplant, URN, and COB claims, to determine pricing under external contracts.
• Perform other duties and responsibilities as assigned.

Benefits

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

What This Job Offers

• Career Level: Mid Level
• Education Level: High school or GED