Claims Processor

We are seeking a detail-oriented Claims Analyst II to join our healthcare claims team. In this role, you will be responsible for reviewing, analyzing, and adjudicating medical claims while ensuring compliance with plan benefits, medical policies, and regulatory guidelines. The ideal candidate will have strong experience in medical claims processing, claims adjudication, and healthcare insurance operations.

Key Responsibilities

• Review, analyze, and adjudicate professional and facility medical claims in accordance with plan benefits, policies, and procedures.

• Determine appropriate claim disposition, including payment, denial, return, or pend status.

• Verify claim accuracy, billing compliance, and completeness of submitted documentation.

• Process approved claims and ensure timely, accurate payments.

• Investigate and resolve suspended or pending claims within established turnaround times.

• Identify and process Coordination of Benefits (COB), Workers' Compensation, and Subrogation claims appropriately.

• Monitor claims processing systems for errors and make necessary corrections or adjustments.

• Review home office claims up to $18,000 for payment approval.

• Perform claim repricing activities, including applying internal and external network discounts.

• Research and obtain additional information from providers, members, or other agencies when needed.

• Maintain thorough documentation of claim decisions, adjustments, and payment activities.

• Process specialty claims, including transplant, URN, and COB claims, according to contractual agreements.

• Maintain department quality standards and productivity goals.

• Stay current on provider contracts, benefit plans, medical policies, authorizations, and utilization management guidelines.

Required Qualifications

• High school diploma or equivalent.

• 2-4 years of medical claims processing experience.

• Experience adjudicating professional and facility healthcare claims.

• Strong understanding of medical claims workflows and payment methodologies.

• Knowledge of:

• Medical terminology

• CPT coding

• ICD-9 and ICD-10 coding

• Coordination of Benefits (COB)

• Subrogation processes

• Ability to interpret member certificates of coverage, plan documents, and medical policies.

• Strong analytical, problem-solving, and organizational skills.

• Proficiency with claims processing systems and healthcare software.

Preferred Qualifications

• Experience using QNXT Claims Workflow.

• Previous experience supporting ACA, Medicaid, Managed Care, or other health plan environments.

• Medical coding experience or coding certification.

• Experience with provider reimbursement methodologies, discounts, and claim repricing.

Job Type & Location

This is a Contract to Hire position based out of Appleton, WI.

Pay and Benefits

The pay range for this position is $19.25 - $19.25/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:
Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave)

Job Type & Location

This is a Contract to Hire position based out of Appleton, WI.

Final date to receive applications

This position is anticipated to close on Nov 3, 2026.

Workplace Type

This is a fully remote position.

About TEKsystems

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change.

That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex,…