Claims Analyst II
Menasha, WI 54952
**Primarily working on commercial claims; opportunity to help with Medicare and potentially the marketplace.
This individual is responsible for reviewing paper and/or electronic claims for processing. Applies specified coding methodology to benefit application and claims payment. Follows established departmental policies and procedures, operating memos and corporate policies and established CMS policies and procedures to process claims and resolve claim issues. Provides decision, research and analysis support to Customer Service.
Essential Job Duties:
- Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision
- Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies
- Process Professional and Facility claims for payment in accordance with members Certificate of Coverage, CMS guidelines, established medical policies and procedures, and plan benefit interpretation while maintaining a high level of confidentiality.
- Review claims to ensure compliance with proper billing standards and completeness of information. Obtain additional information from appropriate persons and/or agency as needed.
- Identifies potential coordination of benefits (COB), Workers Compensation, and Subrogation issues and adjudicates the claims accordingly.
- Understands and accurately applies principles of ICD, CPT HCPCS, Medicare billing codes and DRG coding when processing member claims.
- Investigates and resolves pending claims in accordance with established time frames. Identifies claims needing to be pended/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, CMS requirements, provider discounts, percentages and per diems, enrollee certificates and agreements, authorizations and other utilization management policies, etc.
- 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.
- Maintains and/or improves individual production rate standards and department quality standards.
- Assists in training internal staff as needed
- Performs other duties and responsibilities as assigned.
Hours: 8:00am-4:30pm, Monday-Friday
- Strong oral and written communication skills with the ability to listen mindfully, identify gaps and ask appropriate questions
- Ability to organize one’s work and space to ensure successful completion of assigned tasks within the identified timeframe
- Ability to adapt to new circumstances, information and challenges in a fast-paced environment
- Ability to work independently, as well as part of a team
- Knowledge of current procedural terminology (CPT) and international classification of diseases (ICD-10).
- Knowledge of basic medical terminology, and COB processing
- Basic Word and Excel
- Excellent critical thinking, problem solving, and decision-making skills
- Excellent attention to detail and follow through
- Strong commitment to excellence in customer service with both internal and external customers
Minimum Related Years of Experience (per minimum education) Required:
- 0-2 years of claims processing experience required or 0-2 years of insurance customer service call center required.
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