Medical Claims Analyst (full-time / remote / hybrid)
About the position
The Medical Claims Analyst position is a full-time role with a hybrid remote work arrangement based in Sheboygan, WI. This position does not require working on weekends, holidays, or being on-call, making it an ideal opportunity for those seeking a balanced work-life schedule. Prairie States Enterprises, Inc. is a leading third-party administrator in the benefits industry, providing a comprehensive range of medical benefit management services to self-insured companies and their employees. The company prides itself on delivering these services in-house and adhering to high standards of excellence. In this role, the Medical Claims Analyst will be responsible for the adjudication and processing of medical, dental, and vision claims. This includes interpreting coding and medical terminology in relation to diagnoses and medical procedures. The ideal candidate will possess strong customer service skills, as they will interact with members, Human Resource contacts, employees, providers, and internal staff. The position requires the ability to read and comprehend instructions, draft correspondence, and effectively present information in one-on-one and small group settings. The Medical Claims Analyst will review, research, investigate, adjudicate, and process claims for assigned relationships. They will be accountable for the accurate and timely entry of claims data, ensuring that it meets the department's quality standards. The role also involves identifying potential large claims and understanding the stop-loss process. The analyst will assist in answering overflow phone calls and may be assigned other duties and special projects as needed. This position is essential in maintaining the integrity and efficiency of the claims processing department, contributing to the overall success of Prairie States Enterprises, Inc.
Responsibilities
Review, research, investigate, adjudicate, and process medical, dental, and vision claims.
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Provide high-level customer service when interacting with members, Human Resource contacts, employees, providers, and internal staff.
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Read and comprehend instructions and draft short correspondence and memos.
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Effectively present information in one-on-one and small group situations to customers, clients, and other employees.
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Understand all aspects of plan documents for assigned groups and groups within their assigned pod.
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Demonstrate understanding of electronic claims from exceptions to pass-through audits.
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Identify potential large claims and understand the stop-loss process and pend claims appropriately.
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Perform daily duties and process claims with minimal direction, asking questions appropriately.
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Ensure accurate and timely entry of claims data in accordance with department policies and procedures.
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Meet established productivity and quality standards for claims processing.
Requirements
High School Diploma or GED required.
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Post high school education in the medical field and medical terminology highly preferred.
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1 to 3 years of experience in an insurance or medical office setting.
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Strong customer service and communication skills required.
Nice-to-haves
Experience with claims processing software.
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Knowledge of medical coding and billing practices.
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Ability to work independently and as part of a team.
Benefits
401(k) matching
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Dental insurance
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Disability insurance
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Flexible spending account
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Health insurance
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Paid time off
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Vision insurance
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