Claims Processor

TEKsystems; United States; Teletrabalho; USD 22 000 - 31 000; Tempo integral

Resumo da oferta

TEKsystems seeks a Claims Analyst II to examine and process paper and electronic claims. You will adjudicate, pend, deny, or pay claims per policies and procedures, handling professional and facility claims with strict confidentiality.

You will maintain quality standards, review for proper billing, obtain required information, and resolve issues within established timeframes. Remote work options apply for this role.

Qualificações

• High school diploma or equivalent preferred.
• 2-4 years medical claims processing experience required.
• Knowledge of CPT and ICD-9/ICD-10.
• Experience with ACA, Medicaid, or similar health plans preferred.
• Coding experience preferred.

Responsabilidades

• Process Professional and Facility claims for payment per policies.
• Adjudicate claims by following departmental policies.
• Obtain additional information as needed to complete claims.
• Maintain department quality standards and turnaround times.
• Identify COB, workers' compensation, and subrogation issues.
• Review home office claims for payment up to $18,000.

Conhecimentos

Claims processing

CPT/ICD coding

COB processing

Subrogation knowledge

Formação académica

High School Diploma

Ferramentas

QNXT Claims Workflow

Descrição da oferta de emprego

Description

Job Description

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.

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.

Additional Skills & Qualifications

High school diploma or equivalent preferred.

2-4 years medical 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.

Experience Level

Intermediate Level

Job Type & Location

This is a Contract to Hire position based out of Milwaukee, WI.

Pay and Benefits

The pay range for this position is $19.25 - $19.25/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your jobclassification and length of employment. Benefits are subject to change and may besubject to specific elections, plan, or program terms. If eligible, the benefitsavailable for this temporary role may include the following:Medical, dental & visionCritical Illness, Accident, and Hospital401(k) Retirement Plan Pre-tax and Roth post-tax contributions availableLife Insurance (Voluntary Life & AD&D for the employee and dependents)Short and long-term disabilityHealth Spending Account (HSA)Transportation benefitsEmployee Assistance ProgramTime Off/Leave (PTO, Vacation or Sick Leave)

Job Type & Location

This is a Contract to Hire position based out of Milwaukee, WI.

Application Deadline

This position is anticipated to close on Nov 3, 2026.

Workplace Type

This is a fully remote position.

About TEKsystems

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

About TEKsystems and TEKsystems Global Services

Were a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. Were a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. Were strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. Were building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies. Learn more at TEKsystems.com.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.