Claims Analyst II

Network Health’s success is rooted in its mission to create healthy and strong Wisconsin communities. This mission drives the decisions we make, including the people we choose to join our growing team.

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. Key responsibilities of this position include the following:

• 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.

This position plays a vital role in ensuring accurate and efficient claims processing, contributing to the overall success of Network Health.
Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required), at our office in Brookfield or Menasha, or a combination of both in our hybrid workplace model.
Hours: 1.0 FTE, 40 hours per week between 8am-5pm Monday through Friday.

Check out our 2025 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job 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
• Prior experience with ACA, Medicaid, or similar health plans preferred.
  
• Coding experience preferred.