Claims Analyst - ASO

At Network Health, our mission to create healthy and strong Wisconsin communities guides everything we do-including how we hire. We are currently seeking a Claims Analyst (ASO) to support our growing Third Party Administrator (TPA) line of business.

Our TPA services operate under an Administrative Services Only (ASO) model, where employers fund their employees' health claims directly, while Network Health provides administrative support to manage those claims and related benefits tasks. This self-funded approach allows employers to retain financial risk while gaining greater cost control and flexibility compared to traditional fully insured plans.

In this role, you will responsible for accurately and efficiently processing claims in accordance with established production and quality standards. This role involves investigating claims for potential issues such as fraud, subrogation, coordination of benefits (COB), medical necessity, and policy exclusions. The Claims Analyst collaborates with internal teams and external contacts to gather necessary information, resolve claim issues, and ensure timely processing. They also provide professional written communication to clients, members, providers, brokers, and employers. A strong emphasis is placed on teamwork, maintaining positive working relationships, contributing to process improvements, and supporting departmental goals-especially during times of high volume or backlog.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required), at our office in Brookfield or Menasha, or a combination of both in our hybrid workplace model. Travel to the office in Menasha or Brookfield may be required occasionally for the position, including on first day of orientation.

Hours: 1.0 FTE, 40 hours per week, 8am-5pm Monday through Friday

Check out our 2024 Annual Report video to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job Responsibilities

• Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health
• Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies
• Adjudicates claims for clients by correct and timely application of specific plan document language. Meets hourly production and accuracy standards set by management.
• Provides responsive and professional customer service written correspondence for clients which may include members, providers, brokers and employers.
• Investigates claims for potential fraud, subrogation, coordination of benefits, medical necessity and policy limitations and exclusions. and notifies the appropriate members of the team when further action is needed. Applies policy language accurately.
• Researches and documents information as needed to process claims and provide resolutions by collaborating with other departments within the organization, contacting providers, members and employers to collect missing information or request medical records.
• Maintains good working relationships with all internal and external contacts to ensure optimal level of service. Acts as a team player in all situations.
• Comprehends the need for a sense of urgency with all work activities Process claims in an hourly production environment.
• Works with members of staff on identifying process improvements. Makes regular contributions at team meetings and during one on ones to improve job function. Maintains a positive and professional attitude.
• Assists co-workers as needed in reaching department goals. Assists co-workers during times of claims backlogs.
• Other duties as assigned.

Job Requirements:

• High school diploma or equivalent is required. Some secondary education is preferred.
• 1-3 years claims adjudication experience is required. Knowledge of third party administration concepts is 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
• Coding experience preferred.