Senior Claims Representative Jobs in Appleton, WI

Network Health’s success is deeply rooted in its mission to build healthy and strong Wisconsin communities. This mission shapes every decision we make, including the selection of individuals who join our growing team.
The Member Experience Representative I will support our various line of business by addressing benefit interpretations, claims, authorizations, and other member inquiries in a collaborative and innovative environment. This role involves assisting members with their healthcare questions through phone calls and emails, as well as supporting providers with inquiries about Network Health plans.
Our Member Experience Representatives embody our commitment to “Service Excellence” by guiding members through their healthcare needs. They help members understand their benefits, resolve claim concerns, locate providers, and serve as a resource for healthcare providers. At Network Health, we strive to deliver a better healthcare experience, ensuring members get the help they need with just one call.
We strive to provide amazing service in plain language that our members will understand.  The initial training period is a 6-8 week program with a work schedule of Monday - Friday from 8:00am - 4:30pm.  After your training, you can select a Monday - Friday work schedule of either 8:00am to 4:30pm or 8:30am to 5:00pm.   
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 with our hybrid workplace model.  
Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday.  
Target Start Date: This position has a target start date of September 8, 2026 contingent upon the candidate’s availability to begin employment.
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

• Demonstrate behaviors that align with Network Health's mission, vision, values, and organizational philosophy.
• Consistently comply with all organizational policies, regulatory requirements, credentialing standards, and applicable procedures.
• Respond professionally and efficiently to incoming phone calls from members, customers, providers, and brokers regarding benefits, coverage, claims, billing, authorizations, and other health plan inquiries.
• Utilize active listening and effective questioning techniques to fully understand the caller's needs and achieve first-call resolution whenever possible.
• Accurately document all customer interactions within the appropriate systems and complete required follow-up activities in a timely manner.
• Collaborate with internal departments to resolve outstanding issues and ensure timely, accurate responses to customer inquiries.
• Escalate complex or unresolved issues to a Senior Representative, Supervisor, or other appropriate resource when necessary.
• Meet established departmental quality, productivity, service, and contractual performance standards.
• Perform other duties and responsibilities as assigned.

Job Requirements:

• High school diploma or equivalent
• Strong desire to help others
• Previous experience in the insurance industry is a plus
• Medical terminology background is a plus
• Excellent communication skills including the ability to clearly explain complicated subjects
• Warm and pleasant demeanor over the phone. We want our members to hear your smile!
• The ability to work in several computer systems and multi-screen set-up and know where to find answers