Remote Claims Manager Jobs in Appleton, WI (NOW HIRING)

Description

We are seeking a Claims Analyst II to examine and process paper and electronic claims. In this role, you will determine whether to return, pend, deny, or pay claims in accordance with established policies and procedures. Key responsibilities of this position include the following: Adjudicate claims by following departmental policies, operating memos, and corporate guidelines. Resolve claims and related issues in compliance with policy provisions. Compare claims applications and provider statements with policy files and other records to ensure completeness and validity. Process payments for claims that are approved. Job Responsibilities: Processes Professional and Facility claims for payment in accordance with members Certificate of Coverage, established medical policies and procedures, and plan benefit interpretation while maintaining a high level of confidentiality. Reviews claims to ensure compliance with proper billing standards and completeness of information. Obtains additional information from appropriate person and/or agency as needed. Maintains department quality standards. Maintains established department turn-around processing time. Maintain and/or improves individual production rate standards and department quality standards. Identifies potential coordination of benefits (COB), Workers Compensation, and Subrogation issues and adjudicates claims accordingly. Investigates and resolves pending claims in accordance with established time frames. Identifies claims needing to be pended or suspended. Reviews pending claims timely and denies claims after established time frame is reached without resolution. Monitors computerized system for claims processing errors and make corrections and/or adjustments as needed. Keeps current on group contracts specifics, provider discounts, percentages and per diems, enrollee certificates and agreements, authorizations and other utilization management policies, etc. Reviews home office claims for payment up to $18,000.00. Reviews claims for re-pricing. Enters eligible claim data into appropriate WRAP network re-pricing website. Overrides claims allowed amounts to apply internal/external discounts. Appropriately documents attributes and memos for pertinent information related to claims payment. Processes specialty claims (transplant, URN, COB) to determine appropriate pricing according to external contract. Performs other duties and responsibilities as assigned.

Skills

adjudication, claims adjudication, Claims Processing, EOB, Customer Service, Data Entry, Metrics

Top Skills Details

adjudication,claims adjudication,Claims Processing

Additional Skills & Qualifications

High school diploma or equivalent preferred. 2-4 years claims processing experience required Knowledge of current procedural terminology (CPT) and international classification of diseases (ICD-9 and ICD-10). Medical terminology, COB processing, subrogation. Past experience using QNXT™ Claims Workflow a plus Prior experience with ACA, Medicaid, or similar health plans preferred. Coding experience preferred.

Experience Level

Entry Level

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

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)

This is a fully remote position.

This position is anticipated to close on Sep 11, 2026.

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, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

We’re a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. We’re a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. We’re strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. We’re building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies. Learn more at TEKsystems.com.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.