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Claim Configuration Analyst Jobs in Wisconsin (NOW HIRING)

Mercyhealth

Internal Auditor

Janesville, WI · On-site

$58K - $94K/yr

Analyze audit results, identify trends and areas of risk, and prepare detailed written reports ... configuration. * Research claim processing issues and errors to determine their origin and ...

Mercyhealth

Internal Auditor

Janesville, WI · On-site

$58K - $94K/yr

Analyze audit results, identify trends and areas of risk, and prepare detailed written reports ... configuration. * Research claim processing issues and errors to determine their origin and ...

Imedica

Director, Claims Operations

Madison, WI · On-site

$113K - $194K/yr

... recovery, claim analysis and issue resolution, and provider appeals. A skilled people and ... Partner cross-functionally (Payment Integrity, Customer Service, EDI, Configuration, Finance, IT, ...

All JobsClaim Configuration Analyst JobsClaim Configuration Analyst Jobs in Wisconsin

Claim Configuration Analyst information

What is a claim configuration analyst?

Claim Configuration Analysts are professionals who specialize in setting up and maintaining the rules, processes, and systems that handle insurance claims within an organization. They ensure that claim processing systems are configured accurately to follow policy guidelines, regulatory requirements, and company procedures. Their role often involves analyzing data, troubleshooting issues, and collaborating with IT, claims, and business teams to optimize claim workflows. By ensuring correct system configurations, they help reduce errors, improve operational efficiency, and support timely claim resolutions.

What are the key skills and qualifications needed to thrive as a claim configuration analyst, and why are they important?

To thrive as a Claim Configuration Analyst, you need a strong understanding of healthcare claims processing, benefits administration, and analytical problem-solving, often supported by a degree in business, information systems, or a related field. Familiarity with claims adjudication systems (such as Facets or QNXT), SQL, and potentially industry certifications like Certified Claims Professional (CCP) are commonly required. Attention to detail, effective communication, and the ability to work collaboratively with cross-functional teams are crucial soft skills. These competencies ensure accurate claim system configuration, regulatory compliance, and efficient operations within health insurance organizations.

What are some common challenges faced by claim configuration analysts, and how can they be addressed?

Claim Configuration Analysts often encounter challenges such as interpreting complex insurance policies, ensuring accurate system configuration to minimize claim errors, and keeping up with frequent regulatory changes. Addressing these challenges requires strong analytical skills, attention to detail, and effective collaboration with cross-functional teams like IT, compliance, and claims processing. Regular training and open communication channels help analysts stay updated and maintain high-quality configurations, ultimately reducing errors and improving efficiency.

What is the difference between Claim Configuration Analyst vs Claims Processor?

AspectClaim Configuration AnalystClaims Processor
Primary ResponsibilitiesDesigns and manages claim system setups, analyzes configuration issues, and optimizes claim workflows.Processes individual claims, verifies information, and ensures accurate claim adjudication.
Required Skills & CertificationsKnowledge of insurance systems, data analysis, and possibly certifications like CPCU or similar.Attention to detail, familiarity with claims software, and basic insurance knowledge.
Work EnvironmentTypically office-based, working with IT teams and claims systems.Office or remote, handling claims directly or via claims processing platforms.

The Claim Configuration Analyst focuses on configuring and optimizing claim systems and workflows, while the Claims Processor handles the day-to-day processing of individual claims. Both roles require insurance knowledge, but the analyst role emphasizes system setup and analysis, whereas the processor role emphasizes claim review and verification.

Is claims processing a stressful job?

Claims processing as a Claim Configuration Analyst can be stressful due to tight deadlines, high accuracy requirements, and the need to resolve complex issues efficiently. The role often involves detailed data analysis and communication with stakeholders, which can contribute to work-related stress. However, workload and stress levels vary depending on the organization and individual workload management skills.

What are popular job titles related to Claim Configuration Analyst jobs in Wisconsin?

For Claim Configuration Analyst jobs in Wisconsin, the most frequently searched job titles are:

What job categories do people searching Claim Configuration Analyst jobs in Wisconsin look for?

The top searched job categories for Claim Configuration Analyst jobs in Wisconsin are:

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Cities in Wisconsin with the most Claim Configuration Analyst job openings:

Claim Configuration Analyst jobs near you

Internal Auditor

Mercyhealth

Janesville, WI • On-site

$58K - $94K/yr

Full-time

Medical, Dental, Vision, Life, PTO

Re-posted 20 days ago

Mercy Health rating

6.9

Company rating: 6.9 out of 10

Based on 384 frontline employees who took The Breakroom Quiz

456th of 891 rated healthcare providers

Job description

Conduct comprehensive claims audits to ensure compliance with fee schedules, benefit plans, contractual obligations, service-level agreements, and claim turnaround standards. Evaluate claims processing activities for adherence to industry best practices, federal and state regulatory requirements, organizational policies and procedures, provider contracts, and applicable accreditation standards.

Analyze audit results, identify trends and areas of risk, and prepare detailed written reports summarizing findings, root causes, and recommendations for corrective action and process improvement. Collaborate with internal stakeholders to monitor compliance, improve operational effectiveness, and support regulatory readiness.

MercyCare administers a diverse portfolio of health insurance products, including Medicaid, Exchange, ERISA, and commercial plans, and operates within regulatory frameworks established by the Wisconsin Office of the Commissioner of Insurance (OCI), Illinois Department of Insurance (DOI), and other applicable federal and state agencies. The role requires a strong understanding of health plan operations, claims administration, and regulatory compliance across multiple lines of business.

Essential Duties and Responsibilities

  • Conduct audit interviews with front line staff in all functional areas that fall under claim operations.
  • Test, create flow charts and map operational processes that touch the outcome of claims accuracy.
  • Perform routine and moderately complex audits on claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration.
  • Research claim processing issues and errors to determine their origin and appropriate resolution. Interacts with Operations management regarding trends in order to improve claims processing accuracy and incorporate into training programs, policies and procedures.
  • Create audit reports to document audit findings, which will result in audit recommendations, reports and claims audit criteria enhancements.
  • Perform special project audits and reviews as requested by other departments.


Education and Experience

  • Bachelor's degree in accounting or business administration preferred with concentration in health care also preferred.
  • Minimum 2 years audit experience in health care industry.


Certification and Licensure

The following certifications are preferred:

  • Certified Internal Auditor (CIA) certification
  • Certified Healthcare Auditor (CHA)
  • Certified Public Accountant (CPA)
  • Registered Health Information Administrator (RHIA)


Skills and Abilities

  • Effective written and oral communication skills.
  • Excellent analytical/interpretive skills.
  • High degree of accuracy.
  • Proficiency in application of computers and software programs such as Excel.

PAY RANGE:

$58,797.66 - $94,076.26

Mercyhealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, disability, or protected veteran status.

Mercyhealth offers competitive pay and a comprehensive benefits package including:

  • Medical, Dental, Vision

  • Life & Disability Insurance

  • FSA/HSA Options

  • Generous, accruing paid time off

  • Paid Parental and caregiver leave

  • Career advancement and educational opportunities

  • Tuition and certification reimbursement

  • Certification Reimbursement

  • Well-being Programs

  • Employee Discounts

  • On-Demand Pay

  • Financial Education

  • Annual recognition/awards events

  • Partner appreciation days

  • Family entertainment/attractions discount

  • Community service/improvement opportunities

Click here for more details regarding Mercyhealth Careers Benefit Information.

At Mercyhealth, we don't simply hire people, we empower employee-partners who are passionate about making lives better. As an integrated health system, we deliver exceptional, coordinated across seven hospitals, 85 primary and specialty clinics, and a team of over 7,500 professionals serving northern Illinois and southern Wisconsin.

Mercyhealth has been nationally recognized for our commitment to our people and culture, including:

  • #1 in the nation on AARP's Best Employers for Workers Over 50

  • One of Working Mother magazine's 100 Best Companies for Working Mothers

  • A Top 50 Company and Top 10 Nonprofit for Executive Women

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About Mercyhealth

Sourced by ZipRecruiter

At Mercyhealth, we don’t simply hire people – instead, we empower talented, dedicated health care professionals to provide the highest quality patient care possible with a passion for making lives better. As an integrated health care provider, we provide exceptional, coordinated health care. The organization consists of seven hospitals, 85+ clinics, and more than 7,500 employee-partners to serve patients in 15 counties throughout northern Illinois and southern Wisconsin. We hope you’ll consider becoming the newest member of the Mercyhealth family and join our passion for making lives better!

Industry

Hospitals, fitness and sports centers and health care and social assistance

Company size

10,000+ Employees

Headquarters location

Janesville, WI, US

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