Medical Claims Analyst​/remote​/hybrid

Grow Your Career Where Passion Meets Purpose

At Prairie States, excellence is a shared goal. Over 90 professionals, working together, commit themselves daily to improving the health benefit experience of our members and their families.

We are always looking for talented, ambitious and dedicated people to join our team. If you’re interested in seeing your efforts recognized and appreciated, and in helping people in a meaningful way, please view our current career opportunities.

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

Location: Sheboygan, WI

Job :159

# of Openings:1

This is a full-time position based in our Sheboygan, WI location. The position includes an initial in-person training period of approximately 2-3 months, after which a hybrid remote work arrangement is available. The ideal candidate will be based in Wisconsin. Monday-Friday schedule, 8:30 AM-4:30 PM, with no weekends, holidays, or on-call rotations.

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.

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

• 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.

• 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 strongly preferred.
• Strong customer service and…