Claims Analyst II

Network Health’s success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Claims Analyst II who will examine and process paper claims and/or electronic claims. The person in this role determines whether to return, pend, deny or pay claims within established policies and procedures. Determines steps necessary for adjudication. Follows established departmental policies and procedures, operating memos and corporate policies to resolve claim and claim issues. Settles claims with Claimants in accordance with policy provisions. Compares claims application and/or provider statement with policy file and other records to evaluate completeness and validity of claim. Pays claimant’s amount due.

Essential Duties and 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.

Job 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.
• Past experience using QNXT™ Claims Workflow a plus
• Coding experience preferred.

**This position works out of our Menasha, WI corporate office and is eligible to be a work at home position if candidate meets the work at home eligibility requirements in order to be considered. Candidate pool must live in Northeast Wisconsin as travel may be required to the Menasha office occasionally for meetings. **

Network Health is an Equal Opportunity Employer. We encourage applications from all backgrounds, communities and industries, and are committed to having a team that is made up of diverse skills, experiences and abilities. We are committed to equality and diversity within Network Health.

• WARNING: Please beware of phishing scams that promote work-at-home opportunities and which may also pose as legitimate companies. Please be advised that Network Health recruiter will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for a role with our company. All of our positions require that you first complete an online application.