Claims Analyst
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Job Description
Claims Analyst processing and adjudicating Wisconsin medical insurance claims for TEKsystems. Reviewing benefits, billing, COB, repricing, and specialty claims remotely.
Responsibilities:
- Examine and process paper and electronic claims
- Determine whether to return, pend, deny, or pay claims according to established policies and procedures
- Adjudicate claims 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 for completeness and validity
- Process payments for approved claims
- Process Professional and Facility claims according to coverage certificates, medical policies, procedures, and plan benefit interpretations
- Review claims for billing standards compliance and completeness
- Obtain additional information from appropriate persons or agencies
- Maintain department quality standards and processing turnaround times
- Identify and adjudicate coordination of benefits (COB), Workers Compensation, and Subrogation issues
- Investigate and resolve pending claims within established time frames
- Monitor computerized claims-processing systems for errors and make corrections or adjustments
- Maintain current knowledge of group contracts, provider discounts, percentages, per diems, enrollee certificates, agreements, authorizations, and utilization management policies
- Review home office claims for payment up to $18,000.00
- Review claims for repricing and enter eligible claim data into the WRAP network repricing website
- Override allowed amounts to apply internal or external discounts
- Document pertinent claims-payment attributes and memos
- Process specialty claims, including transplant, URN, and COB, according to external contract pricing
- Perform other assigned duties
Requirements:
- High school diploma or equivalent preferred
- 2-4 years medical claims processing experience required
- Knowledge of current procedural terminology (CPT)
- Knowledge of international classification of diseases (ICD-9 and ICD-10)
- Knowledge of medical terminology
- Knowledge of COB processing
- Knowledge of subrogation
- Past experience using QNXT Claims Workflow a plus
- Prior experience with ACA, Medicaid, or similar health plans preferred
- Coding experience preferred
Benefits:
- Medical, dental & vision
- Critical Illness, Accident, and Hospital coverage
- 401(k) Retirement Plan with pre-tax and Roth post-tax contributions
- 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)
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