Medicaid Senior Claims Analyst

Network Health is seeking an experienced Senior Medicaid Claims Analyst to join our growing team. This critical role is responsible for complex claims adjudication and resolution, ensuring compliance with Medicaid regulations, and serving as a subject matter expert for claims processing policies and procedures. The ideal candidate will have extensive experience in Medicaid claims processing, strong analytical skills, and a commitment to maintaining the highest levels of accuracy, confidentiality, and customer service.

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 will be required occasionally for the position, including on first day.

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

Check out our 2024 Community Report 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:

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  Process complex Medicaid professional and facility claims in accordance with members' Certificates of Coverage, state Medicaid guidelines, plan policies, and benefit interpretations.

  
  
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  Research, investigate, and resolve escalated or high-dollar claims, ensuring compliance with all applicable Medicaid requirements and timely processing standards.

  
  
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  Serve as a resource for junior analysts and provide training, guidance, and quality reviews to ensure department accuracy and efficiency standards are met.

  
  
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  Identify and resolve issues related to Coordination of Benefits (COB), Workers' Compensation, Subrogation, and other special claim situations.

  
  
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  Monitor system edits, claim suspensions, and re-pricing requirements; perform adjustments and overrides as appropriate.

  
  
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  Collaborate with internal departments such as Provider Relations, Customer Service, and Compliance to resolve complex claims inquiries.

  
  
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  Stay current on state Medicaid regulations, policy changes, and industry best practices; communicate relevant updates to the team.

  
  
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  Review and process claims within established monetary authority levels.

  
  
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  Maintain production and quality standards while handling confidential member information with care.

  
  
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  Participate in audits, special projects, and process improvement initiatives as assigned.

  
  

Job Requirements:

• HS Diploma or equivalency required
• Additional course work in Medical Terminology/Advanced Medical Terminology required
• Knowledge of Federal and State mandates and regulation related to claims and coding preferred.
• 3-5 years of experience in claims processing
• Strong oral and written communication skills with the ability to listen mindfully, identify gaps and ask appropriate questions
• Ability to organize one's work and space to ensure successful completion of assigned tasks within the identified timeframe
• Ability to adapt to new circumstances, information and challenges in a fast paced environment
• Ability to work independently, as well as part of a team
• Knowledge of current procedural terminology (CPT) and international classification of diseases (ICD-10).
• Medical terminology, COB processing
• Basic Word and Excel skills
• Excellent critical thing, problem solving, and decision making skills
• Excellent attention to detail and follow through
• Strong commitment to excellence in customer service with both internal and external customers

Network Health is an Equal Opportunity Employer