Claims Assistant
Group Health Cooperative of South Central Wisconsin - Wisconsin

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Full time (40 hrs/week, 1.0 FTE) position located at our west side Administrative Offices.

Claims Assistant

The Claims Assistant position enters claims data into the computer and processes capitated claims that do not have referral requirements. The position also provides clerical support to the Claims Department including answering the incoming phone line and directing calls appropriately. The Claims Assistant works under the general direction, guidance and supervision of the Claims Supervisor.

The incumbent knows and abides by all Group Health Cooperative of South Central Wisconsin (GHC-SCW) organizational and departmental policies, sets personal standards and strives for high quality work in completing assignments, performs job duties in a timely manner, and represents the organization in a positive manner. The incumbent understands our Mission, Vision and Common Values (stated below) and is committed to promote these values in behavior and attitude.

Our Mission Statement: To provide accessible, comprehensive, high quality healthcare and outstanding service in an efficient and personalized manner on a prepaid basis to persons in the GHC-SCW service area.

Our Vision: To be a leader among HMO’s in providing high-quality medical care, impeccable service and competitive benefit levels and premium rates.

Our Common Values:
  • Patient Centered: When health insurers and health care providers are brought together under one roof, we are better together. Our care team model focuses on supporting the needs of our patients/members and providing the best in safe, high quality coordinated health care. Members and their providers participate in making meaningful decisions that lead to better outcomes.
  • Quality Driven: When members and their providers each participate meaningfully in the decisions that lead to better health care, we are better together. GHC-SCW continues its tradition of providing proactive health promotion and disease management outreach to our members to consistently achieve high quality health care accreditation.
  • Innovation: When we work to lift each other up, show appreciation and collaborate in the best interests of the member, we are better together. GHC-SCW has made innovative advancements which include the implementation of an electronic medical records system (EMR) and GHC-SCW MyChartSM, access to innovative Complementary Medicine benefits and Wellness reimbursement services.
  • Community Involved: When we join with our community to further the causes for which we share a common concern, we are better together. We are proud to promote programs that strengthen lives, and make our community a safer, stronger and healthier place to live and grow. GHC-SCW employees share their time and talent; and we recognize that the value of what we give is also what we gain – for our employees, our members and our community.
  • Not for Profit Cooperative: When we share a common purpose, a common voice and a common vision, we are better together. We use our surpluses to improve clinics, enhance health care benefits and give back to the community. Our members, not our profits, are our priority. We have a unique “cooperative” governance structure which works directly for our members.

1. High school graduate or equivalent required.
2. Prior administrative office or clerical experience preferred. Previous experience in claims resolution /processing or closely related work in an insurance or healthcare environment is preferred but not required.
3. Knowledge of and ability to use computers including database, word processing, email, and calendar programs. Ability to learn and use billing system software. Experience with EPIC systems is desirable but not required.
4. Ability to type 35 w.p.m. with minimal errors.
5. Knowledge of or ability to learn and accurately apply claims processing techniques, procedures and practices in a timely manner required
6. Good customer services skills required, including the ability to build and maintain effective working relationships with internal and external customers.
7. Ability to work independently and harmoniously with others required.
8. Ability to accurately process/resolve a high volume of an immense variety of incoming claims and inquiries is required.
9. Good organizational skills required. Must be detail oriented and work with a high degree of accuracy.
10. Ability to accurately file numerically and alphabetically required.
11. Ability to analyze, plan, explain, and investigate required.
12. Good verbal and written communication skills required.
13. Ability to maintain patient confidentiality required. Knowledge of or ability to learn HIPAA requirements.
14. Ability to sit and stand intermittently required.
15. Ability to sit and enter at a key board for extended periods of time required.


  • Ability to treat others with dignity, respect, and courtesy required.
  • Ability to follow operating procedures and practices to ensure the highest level of patient/ member safety and care.
  • Ability to maintain patient, employee, and proprietary confidentiality required.
  • Ability to consistently meet or exceed customer expectations in performing own work required.
  • Ability to use effective customer service techniques and effective interpersonal skills required.
  • Ability to act professionally and remain calm in stressful situations required.
  • Ability to communicate effectively in-person and in all forms of communication required.
  • Ability to work and problem solve independently as well as an integral part of a team required.
  • Ability to pay attention to detail required
  • Ability to be flexible and adapt to changing situations required.
  • Ability to adhere to punctuality/attendance standards required.
  • Ability to provide professional image as outlined in the professional casual dress policy required.
SUPERVISED BY: Claims Supervisor

SUPERVISES: This position does not supervise subordinate staff.



1. Data entry of claims. 70%

a. Enter claim data into EPIC per instructions.
b. Proof accuracy of entered data prior to accepting the claim.

2. Processing of capitated claims as assigned. 10%

a. Process capitated claims which do not have referral requirements.
b. Resolve pended claims as defined by supervisor.

3. Performance of clerical support for Claims Department. 15%

a. Maintain letter templates once approved by Supervisor.
b. Deliver out-going mail to appropriate bins.
c. Provide telephone support to department. Answer phone calls, take accurate messages, direct calls to appropriate persons within GHC.
d. Maintain department spreadsheets, as needed.
e. Print and mail department letters.
f. Perform other general clerical duties as assigned.
g. Record claim information on cash receipts.
h. Responsible for organizing/packing documents for off-site storage
i. Responsible for maintaining an inventory of documents stored off-site.
j. Use daily report to enter repricing amount for PPO electronic claims.
k. Request claims via a letter when a statement is received
l. Communicate via e-mail to vendors when refund requests are outstanding
m. Process charges from the Corporate Walgreens Report twice a month.

4. Scanning Documents 5%

a. Batch and scan incoming mail into ONBASE
b. Index the image in the appropriate ONBASE folder
c. Trouble shoot when there is an imaging issue in ONBASE

5. Performance of other duties as assigned by supervisor.


Provision of department/team support to maintain a pleasant work environment.

  • Look for ways to support others in their work.
  • Develop and maintain cooperative work relationships.
  • Approach individuals directly regarding suggestions and concerns and provide constructive feedback.
  • Attend and participate in department/team and corporate meetings.
Performance of other duties as assigned.

  • Stay current with company, department and job-specific information necessary to perform job.
  • Keep GHC-SCW’s work environment clean and organized.
  • Report suspicious, unethical or illegal conduct and cooperate with approved investigations and inspections.
To comply with the Americans with Disabilities Act (ADA), which prohibits discrimination against qualified individuals on the basis of disability, it is necessary to specify the physical and environmental conditions of the essential duties of the job. The demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Check the frequency and number of hours a day the worker is required to do the following specific types of activities:
a. Sitting x X
b. Walking x x
c. Standing x x
d. Bending x x
e. Squatting x x
f. Climbing x x
g. Kneeling x x
h. Twisting x x
i. Lifting x x

0-20 lbs. 20-30 lbs. 40-60 lbs. Over 60 lbs.

2a. HAND MANIPULATION REQUIRED? __x__Yes (If yes, complete a,b,c,d,e) _____No
Fine manual dexterity required.
2b. Repetitive hand movements? ____x_Yes _____No
Ability to use a keyboard extensively required.

2c. Simple Grasping? Right Hand__x___
Yes__x___ No_____ Left Hand__x___
Yes__x____ No_____

2d. Power Grasping?
Right Hand__x___
Yes__x___ No_____
Left Hand__x___
Yes__x____ No_____

2e. Pushing Pulling? Right Hand__x___
Yes__x___ No_____ Left Hand__x___
Yes___x___ No_____

2f. Fine manipulation: Right Hand__x___
Yes___x__ No_____ Left Hand__x___
Yes___x___ No_____

3. (a) Does the job require worker to reach or work above the shoulder? ___x_Yes _____No Frequency: Occasionally
(b) Reaching at or below shoulder level? __x__Yes _____No _____Frequency: Occasionally

4. Does the job require use of his/her feet to operate foot controls or _____Yes __x___No
for repetitive movement?

5. Are there special visual or auditory requirements? ___x__Yes _____No
Describe: Working with computer terminal
Ability to see near, mid and far range required. Ability to speak and hear.

a. Does the employee work near moving mechanical parts; in high, precarious places; and in outside weather conditions? ______Yes ___x___No
b. Is the employee exposed to fumes or airborne particles? ______Yes ___x___No

This position requires job related duties that may include exposure to biohazards such as blood, bodily fluids and tissues. ______Yes ___x___No

We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.

Group Health Cooperative of South Central Wisconsin - 2 years ago - save job