Claims Representative

Sanford Health•Remote WI, WI

4d•$16 - $26•Onsite

About The Position

Responsible for processing health insurance claims submitted via paper or electronically by providers and members. Proficient understanding of Tapestry functionality. Proficient knowledge to releases health insurance claims for payment, understands claims codes according to the defined workflows. Proficient in the processing of claim adjustments based on appeals, configuration and/or benefit change. Basic knowledge of coordination of benefit functions and rules, a basic understanding of third party liability, subrogation and third party processing. Evaluates claims that need additional information prior to processing. Determines proper benefit levels that apply to claims per the certificate of insurance and/or the summary of plan documents. Understands the specific product lines. Understands accumulators for accurate monitoring of maximum out of pocket expenses for claims processing. Mentoring of teammates through peer-to-peer conversations. Processes large quantities of detailed information with high levels of accuracy. Investigates beneath the surface of an issue to focus systematically on root causes; communicates findings with the Senior Claims Representative. Requires analytical ability and keen attention to detail with a high degree of accuracy in work. Must maintain confidentiality. Other duties as assigned.

Requirements

High school diploma or equivalent required.
Two years of applicable experience required.
Knowledge of benefits, summary plan documents, certificates of insurance, and explanation of benefits.

Nice To Haves

Associate degree preferred.
Two years of medical claims processing experience is preferred.

Responsibilities

Processing health insurance claims submitted via paper or electronically by providers and members.
Releasing health insurance claims for payment.
Understanding claims codes according to defined workflows.
Processing claim adjustments based on appeals, configuration, and/or benefit changes.
Evaluating claims that need additional information prior to processing.
Determining proper benefit levels that apply to claims per the certificate of insurance and/or the summary of plan documents.
Understanding specific product lines.
Understanding accumulators for accurate monitoring of maximum out-of-pocket expenses for claims processing.
Mentoring teammates through peer-to-peer conversations.
Processing large quantities of detailed information with high levels of accuracy.
Investigating beneath the surface of an issue to focus systematically on root causes and communicating findings with the Senior Claims Representative.
Maintaining confidentiality.