Claims Analyst

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 (ASO) who will be responsible for medical claim analysis for the Network Health Administrative Services Only (ASO) line of business. Responsibilities for this position will also include benefit determination ensuring claims are processed accurately and timely in an automated environment.

Essential Job Duties:

• Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health
• Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies
• Adjudicates claims for clients by correct and timely application of specific plan document language. Meets hourly production and accuracy standards set by management.
• Provides responsive and professional customer service written correspondence for clients which may include members, providers, brokers and employers.
• Investigates claims for potential fraud, subrogation, coordination of benefits, medical necessity and policy limitations and exclusions. and notifies the appropriate members of the team when further action is needed. Applies policy language accurately.
• Researches and documents information as needed to process claims and provide resolutions by collaborating with other departments within the organization, contacting providers, members and employers to collect missing information or request medical records.
• Maintains good working relationships with all internal and external contacts to ensure optimal level of service. Acts as a team player in all situations.
• Comprehends the need for a sense of urgency with all work activities Process claims in an hourly production environment.
• Works with members of staff on identifying process improvements. Makes regular contributions at team meetings and during one on ones to improve job function. Maintains a positive and professional attitude.
• Assists co-workers as needed in reaching department goals. Assists co-workers during times of claims backlogs.
• Other duties as assigned.

Minimum Education Required:
High school diploma or equivalent is required. Some secondary education is preferred.

Minimum Related Years of Experience (per minimum education) Required:

• 1-3 years claims adjudication experience is required. Knowledge of third party administration concepts is 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.

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.

We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.

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