Sanford Health is an integrated healthcare and health insurance system serving communities across America’s heartland. Headquartered in Sioux Falls, South Dakota, it supports more than 1.4 million patients and nearly 200,000 health plan members through a broad network of medical centers, clinics, senior living communities, physicians, and advanced practice providers. Its work spans direct patient care, insurance, clinical research, and personalized genetic medicine, with specialized programs in areas including cancer, orthopedics, women’s health, and genetics.
Associate Health Claims Representative – Sanford Health (Wisconsin Remote)
Process and validate health insurance claims for Sanford Health, applying plan guidelines to determine coverage and payment.
Description
- Process paper and electronic health insurance claims submitted by providers and members
- Release claims for payment through established workflows
- Validate claims against health plan cost-sharing rules, limits, and exclusions
- Check claims for completeness and accuracy
- Apply medical necessity and eligibility guidelines to assess coverage
- Work assigned pending and error reports
- Determine benefit levels using summary plan language
- Request additional information when needed
- Respond to information requests from other Sanford Health Plan departments
- Refer complex claims to senior or lead claims representatives
- Track maximum out-of-pocket expenses using accumulators
- Carry out other assigned duties
Requirements
- High school diploma or equivalent
- At least one year of relevant experience
- Demonstrated computer literacy
- Ability to maintain confidentiality
- Basic knowledge of Microsoft Office
- Analytical skills and close attention to detail, with a high level of accuracy
- Some college coursework preferred
- At least one year of medical claims processing experience preferred