Medical Claims Analyst
Prairie States Enterprises, Inc., a Green Bay, WI-based third-party administrator of self-funded health plans, is seeking a Medical Claims Analyst. In this role, you will review, analyze, and adjudicate medical and dental claims, ensuring accuracy, benefit compliance, and cost containment for employer-sponsored plans. You will verify eligibility, coding, and documentation, investigate discrepancies, and collaborate with care management and service teams to support positive member outcomes. This position thrives in our collaborative, integrity-driven culture and offers opportunities to deepen your expertise in self-funded benefits administration while contributing to process improvements and exceptional client service.
Responsibilities
- Review, analyze, and adjudicate medical and dental claims for accuracy and plan compliance
- Verify eligibility, benefits, coding, and documentation against plan provisions and regulations
- Identify and resolve claim discrepancies, overpayments, and coordination of benefits issues
- Apply cost-containment guidelines and escalate complex or high-cost claims as needed
- Collaborate with care management and customer service teams to support member outcomes
- Respond to internal and external inquiries regarding claim status and determinations
- Maintain detailed, accurate records in claims administration systems
- Ensure compliance with HIPAA and other regulatory requirements
- Contribute to process improvements and best practices in claims operations
Required Skills
- Medical claims adjudication
- Health insurance benefits interpretation
- Medical billing and coding (CPT, ICD, HCPCS)
- Claims administration systems
- Data entry accuracy
- HIPAA and regulatory compliance
- Cost containment analysis
- Problem solving and investigation
- Written and verbal communication
- Excel and basic data analysis
