Medicare Claims Processor (Remote To Wisconsin Only)
About the position
We are seeking a Claims Analyst II to examine and process both paper and electronic healthcare claims. In this role, you will determine whether claims should be returned, pended, denied, or paid in accordance with established policies, procedures, and benefit plans. This position plays a critical role in ensuring accurate, timely claim adjudication while maintaining confidentiality and quality standards.
Must be able to pick up equipment from either our Menasha or Brookfield office.
Fully Remote (Wisconsin Residents Only)
Schedule: Full‑time (40 hours/week)
Responsibilities
• Adjudicate professional and facility claims in accordance with member Certificates of Coverage, medical policies, and plan benefits.
• Review claims for accuracy, proper billing standards, and completeness of information.
• Determine appropriate claim disposition (pay, deny, pend, or return) within established timeframes.
• Obtain additional or missing information from providers, members, or internal partners as needed.
• Maintain department quality standards and required turnaround times.
• Identify and process Coordination of Benefits (COB), Workers’ Compensation, and Subrogation claims.
• Investigate and resolve pending claims; deny claims when resolution timelines are exceeded.
• Monitor claims processing systems for errors and make necessary corrections or adjustments.
• Review claims for re‑pricing and apply internal or external provider discounts as appropriate.
• Review home office claims for payment up to $18,000.
• Process specialty claims (e.g., transplant, URN, COB) according to external contract requirements.
• Accurately document claim decisions, attributes, and memos.
• Stay current on group contracts, provider discounts, authorizations, and utilization management policies.
• Perform additional duties as assigned.
Requirements
• 2–4 years of healthcare claims processing experience
• Knowledge of:
• Medical terminology
• CPT and ICD‑9/ICD‑10 coding
• Coordination of Benefits (COB), subrogation
• Ability to manage confidential information with accuracy and professionalism
• Strong attention to detail and time‑management skills
• Must reside in Wisconsin
• Eligible to work:
• Fully remote (home office requires reliable internet)
• Menasha office
• Brookfield office
• Hybrid model
• Equipment must be picked up in Menasha or Brookfield
Nice-to-haves
• Medicaid or ACA plan experience
• Claims adjudication experience
• Coding experience
• Prior experience with QNXT™ Claims Workflow
Benefits
• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• 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)
Apply tot his job
Apply To this Job
We are seeking a Claims Analyst II to examine and process both paper and electronic healthcare claims. In this role, you will determine whether claims should be returned, pended, denied, or paid in accordance with established policies, procedures, and benefit plans. This position plays a critical role in ensuring accurate, timely claim adjudication while maintaining confidentiality and quality standards.
Must be able to pick up equipment from either our Menasha or Brookfield office.
Fully Remote (Wisconsin Residents Only)
Schedule: Full‑time (40 hours/week)
Responsibilities
• Adjudicate professional and facility claims in accordance with member Certificates of Coverage, medical policies, and plan benefits.
• Review claims for accuracy, proper billing standards, and completeness of information.
• Determine appropriate claim disposition (pay, deny, pend, or return) within established timeframes.
• Obtain additional or missing information from providers, members, or internal partners as needed.
• Maintain department quality standards and required turnaround times.
• Identify and process Coordination of Benefits (COB), Workers’ Compensation, and Subrogation claims.
• Investigate and resolve pending claims; deny claims when resolution timelines are exceeded.
• Monitor claims processing systems for errors and make necessary corrections or adjustments.
• Review claims for re‑pricing and apply internal or external provider discounts as appropriate.
• Review home office claims for payment up to $18,000.
• Process specialty claims (e.g., transplant, URN, COB) according to external contract requirements.
• Accurately document claim decisions, attributes, and memos.
• Stay current on group contracts, provider discounts, authorizations, and utilization management policies.
• Perform additional duties as assigned.
Requirements
• 2–4 years of healthcare claims processing experience
• Knowledge of:
• Medical terminology
• CPT and ICD‑9/ICD‑10 coding
• Coordination of Benefits (COB), subrogation
• Ability to manage confidential information with accuracy and professionalism
• Strong attention to detail and time‑management skills
• Must reside in Wisconsin
• Eligible to work:
• Fully remote (home office requires reliable internet)
• Menasha office
• Brookfield office
• Hybrid model
• Equipment must be picked up in Menasha or Brookfield
Nice-to-haves
• Medicaid or ACA plan experience
• Claims adjudication experience
• Coding experience
• Prior experience with QNXT™ Claims Workflow
Benefits
• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• 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)
Apply tot his job
Apply To this Job