Medical Claims Analyst (full-time / remote / hybrid)

MEDICAL CLAIMS ANALYST (FULL-TIME / REMOTE / HYBRID) This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location. No weekends, holidays or on-call rotations. Ideal candidate will work in Wisconsin. Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees. We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence. Job Summary Position responsibilities include the adjudication and processing of medical, dental, and vision claims while interpreting coding and medical terminology in relationship to the diagnosis and medical procedures. This position requires high level skills in customer service, claims processing, and internal interface with other departments

Summary

Of Essential Job Functions

• Provides claims adjudication services by reviewing, researching, investigating, adjudicating and processing claims for assigned relationships.
• Provides high-level customer service when interacting with members, Human Resource contacts, employees, providers, and internal staff.
• Has the ability to read and comprehend instructions and draft short correspondence, and memos. Also has the ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
• Understands all aspects of plan documents for assigned groups, and groups within their assigned pod.
• Demonstrates understanding of electronic claims from exceptions to pass-through audits. Should also be able to identify potential large claims and have a good understanding of the stop-loss process and pend claims appropriately.
• Performs daily duties and processes claims with minimal direction and asks questions appropriately.
• Is responsible and accountable for the accurate and timely entry of claims data. Claims data must be entered with a high level of quality and in accordance with department claims policies and procedures.
• Consistently meets established productivity and quality standards:
• Minimum turn-around time is 10 days for clean claims. Claims requiring further investigation will be paid within 1 month unless extenuating circumstances arise and are documented.
• Once additional information is received, claims must be paid within 10 days from receipt of the documentation.
• Required to meet the department standards related to procedural and financial accuracy.
• Assists in answering overflow of outside phone calls, directing the call to the appropriate person or handling the call if that person is not available.
• Other Claims Dept duties and special projects as assigned.

Position Requirements

• High School Diploma or GED required. Post HS education in medical field and medical terminology highly preferred.
• Experience – 1 to 3 years experience in an insurance or medical office setting.
• Strong customer service and communication skills required.

COMPETENCIES

• Change Management – Accepts, supports, and executes assignments in conditions of change which support attaining department goals.
• Effective Communication – Demonstrates effective and responsive communications following the appropriate reporting structure.
• Accountability/Results – Achieves and/or exceeds result based goals that were specific, measurable, and timely.
• Teamwork – Demonstrates teamwork behaviors and makes positive contributions and which support the achievement of department goals.
• Customer Satisfaction – Dedicated to the PSE service model and meets or exceeds PSE customer satisfaction expectations in providing exemplary service.
• Professional Growth – Takes ownership of one’s professional growth within one’s current position and to advancement at PSE.

PHYSICAL DEMANDS / WORK ENVIRONMENT This is sedentary position which requires the individual to sit for long periods of time and the proper positioning/posturing for extensive viewing of computer screens and computer related work is required. It is encouraged that individuals intermix this sedentary time with periodic movement within one’s office space and/or to other office areas to counteract the sedentary nature of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. To the selected candidate, we offer: Competitive compensation based on experience and a comprehensive benefit package provided to include Medical, Dental, Vision, Life, STD/LTD, FSA, Paid Time Off, personal days, 401k with match, wellness and exercise membership and more. Click HERE to view our full-time benefits flyer. Opportunity for meaningful career growth within a results-driven company and our company culture is one of ambition, integrity, empowerment, teamwork and a passion for personal and company success. If this sounds like you and you’re seeking career growth with an exciting new career path in overseeing the quality of health care for our clients and their members, please send your cover letter and resume following the instructions for this site. Prairie States Enterprises Equal Opportunity Employer Apply tot his job Apply To this Job