Claims Processor

TEKsystems•Appleton, WI

7d•$19 - $19•Remote

About The Position

The Claims Processor will review, analyze, and adjudicate professional and facility medical claims in accordance with plan benefits, policies, procedures, and regulatory guidelines. The role determines claim dispositions, verifies accuracy and documentation, processes approved claims and payments, and investigates suspended or pending claims. It also involves specialty claims, repricing, and coordination of benefits work, while maintaining quality and productivity standards.

Requirements

High school diploma or equivalent.
2–4 years of medical claims processing experience.
Experience adjudicating professional and facility healthcare claims.
Strong understanding of medical claims workflows and payment methodologies.
Knowledge of medical terminology, CPT coding, ICD-9 and ICD-10 coding, Coordination of Benefits (COB), and subrogation processes.
Ability to interpret member certificates of coverage, plan documents, and medical policies.
Strong analytical, problem-solving, and organizational skills.
Proficiency with claims processing systems and healthcare software.

Nice To Haves

Experience using QNXT Claims Workflow.
Previous experience supporting ACA, Medicaid, Managed Care, or other health plan environments.
Medical coding experience or coding certification.
Experience with provider reimbursement methodologies, discounts, and claim repricing.

Responsibilities

Review, analyze, and adjudicate professional and facility medical claims according to plan benefits, policies, and procedures.
Determine claim disposition, including payment, denial, return, or pend status.
Verify claim accuracy, billing compliance, and completeness of submitted documentation.
Process approved claims and ensure timely, accurate payments.
Investigate and resolve suspended or pending claims within established turnaround times.
Identify and appropriately process Coordination of Benefits (COB), Workers' Compensation, and Subrogation claims.
Monitor claims processing systems for errors and make necessary corrections or adjustments.
Review home office claims up to $18,000 for payment approval.
Perform claim repricing activities, including applying internal and external network discounts.
Research and obtain additional information from providers, members, or other agencies when needed.
Maintain thorough documentation of claim decisions, adjustments, and payment activities.
Process specialty claims, including transplant, URN, and COB claims, according to contractual agreements.
Maintain department quality standards and productivity goals.
Stay current on provider contracts, benefit plans, medical policies, authorizations, and utilization management guidelines.

Benefits

Medical insurance
Dental insurance
Vision insurance
Critical Illness, Accident, and Hospital coverage
401(k) retirement plan with pre-tax and Roth post-tax contributions available
Voluntary life and AD&D insurance for the employee and dependents
Short- and long-term disability
Health Spending Account (HSA)
Transportation benefits
Employee Assistance Program
Time off/leave, including PTO, vacation, or sick leave (eligibility and terms apply)