Contract Utilization Review Jobs in Appleton, WI

Network Health’s success is rooted in its mission to create healthy and strong Wisconsin communities. Network Health is seeking a COB and Recovery Analyst who will use their advanced knowledge of refunds and recoveries and Medicare Part D coordination of benefits to maintain and drive improvements to our refund and recovery operations and Medicare Part D COB process.

Individuals in this role will help develop departmental policies and procedures to be followed. Investigates potential refunds and processes requests from Providers and Members due to overpayment or inaccurate payments due to COB or various other reasons. Medicare Part D COB is responsible for accurate coordination to ensure our PBM has correct information, preventing members from prescription delays.

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). Travel to the corporate office in Menasha 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 2025 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:

• Maintain reports for tracking voluntary refunds, recoup requests and the negative vendor report
• Keeps current on all business programs, including, products offered, group contracts and certificates, provider discounts, percentages and per diems, authorizations, and other utilization management policies, etc.
• Acts as a liaison between Payment Integrity and other operational departments for claim recovery issue resolution.
• Reviews and follows up on open work items to ensure resolution is within established timeframes
• Works closely with refunds and recoveries to identify root-cause for COB related refunds and recoveries
• Assumes responsibility for accuracy, timeliness and efficiency of COB claims following established guidelines
• Assist other departments with COB/Medicare Part D appropriate claims payment questions and helps resolve claims adjudication disputes related to COB
• Identifies and reports issues with COB/MSP identification or processing training and assists in addressing COB training opportunities.
• Works professionally with members, employers, providers, other insurance carriers and CMS with regard to verification and update of member information to ensure accuracy
• Manage monthly and annual Medicare Part D letters and corresponding updates with ESI
• Responsible for complete and accurate documentation of all information received in all applicable member records and databases
• Assists leadership in decision-making and provides all relevant information accurately and timely
• Ensures department desk procedures related to role are current and complete
• Review and respond to CMS Demand Letters for group health plans
• Assists in addressing training opportunities
• Actively participates in shared accountability and commitment for departmental and organization-wide results. Support departmental/team goals and objective

Job Requirements:

• Minimum of 3 years combined operations/customer service experience within the health insurance industry
• 1-3 years COB, Claims, Refunds and Recoveries or related work
• Excellent communication, critical thinking, and decision-making skills
• Knowledge of process improvement/maximum operational efficiency preferred
• Proficiency in MS Word, Excel, Outlook
• Working knowledge of COB, MSP and Medicare Part D

Network Health is an Equal Opportunity Employer.