REMOTE POSITION / CLAIMS PROCESSOR

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. 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.
Maintains department quality standards.
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.
adjudication, claims adjudication, Claims Processing, EOB, Customer Service, Data Entry, Metrics
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.
Past experience using QNXT™ Claims Workflow a plus
Prior experience with ACA, Medicaid, or similar health plans preferred.
Coding experience preferred.
Entry Level
This is a Contract to Hire position based out of Appleton, WI.
Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.
If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)
This is a fully remote position.
Application Deadline
We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
We're a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. We're a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. We're strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. We're building tomorrow by delivering business outcomes and making positive impacts in our global communities. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.