Remote Claims Adjudication Specialist

TEKsystems; Menasha (WI); On-site; USD 25,000 - 29,000; Full time

Benefits offered by this job

Medical, dental & vision

401(k) Retirement Plan

Life Insurance

Job summary

TEKsystems is seeking a detail-oriented Claims Analyst to review and process both paper and electronic claims while ensuring compliance with policies and guidelines. This fully remote contract-to-hire role is based out of Menasha, WI, with a starting pay of $19.25 per hour and a range reflective of market norms in a remote US setting.

You will evaluate claims, determine actions, and support timely, accurate resolution.

Qualifications

• Strong analytical skills and attention to detail.
• Ability to interpret policies, procedures, contracts, and benefit plans.
• Experience processing or adjudicating healthcare claims preferred.
• Strong problem-solving and research abilities.
• Proficiency with claims processing systems and computer applications.
• Ability to manage confidential information with professionalism and discretion.
• Excellent organizational skills with the ability to meet productivity and quality goals in a fast-paced environment.

Responsibilities

• Review, analyze, and adjudicate professional and facility claims in accordance with benefit plans and procedures.
• Determine whether claims should be approved, denied, returned, suspended, or pended based on policy guidelines and documentation.
• Verify claim accuracy, completeness, and compliance with billing standards.
• Research and gather information from providers, members, or other sources as needed to support claim processing.
• Process approved claims for payment while maintaining confidentiality and data integrity.
• Investigate and resolve pending claims within service level timeframes.
• Identify and handle COB, Workers' Compensation, and Subrogation-related claims appropriately.
• Monitor claims processing systems for errors and make corrections or adjustments.
• Apply contract terms, provider discounts, reimbursement methodologies, and benefit interpretations during adjudication.
• Review and process claims requiring specialized pricing, including transplant, network repricing, and COB claims.
• Enter claim data into repricing systems and apply internal or external discount arrangements as needed.
• Maintain thorough documentation related to claim decisions and payment activities.
• Meet established productivity, turnaround time, and quality standards.
• Stay current on policy updates, benefit changes, provider agreements, and reimbursement guidelines.
• Perform additional duties and special projects as assigned.

Skills

Analytical skills

Policy interpretation

Healthcare claims experience

Problem solving

Claims systems

Confidentiality

Organization

Tools

Claims processing software

Job description

TEKsystems is seeking a detail-oriented Claims Analyst to review and process both paper and electronic claims while ensuring compliance with policies and guidelines. This fully remote contract-to-hire role is based out of Menasha, WI, with a starting pay of $19.25 per hour and a range reflective of market norms in a remote US setting.

You will evaluate claims, determine actions, and support timely, accurate resolution.