Claims Production Professional II

Title: Claims Production Professional II
Company: Confidential
Location: Fargo, ND - Onsite
Employment Type: 12-Month Contract

Overview
We are seeking detail-oriented Claims Production Professionals to join our Claims Operations team and help deliver timely, accurate claims processing that supports an exceptional member and provider experience. In this role, you will investigate, analyze, and adjudicate medical claims across multiple benefit plans while ensuring compliance with contract provisions, internal policies, and quality standards.
Success in this position requires balancing productivity with accuracy in a fast-paced environment. The ideal candidate is naturally analytical, enjoys solving problems, adapts quickly to changing priorities, and can independently make sound decisions while maintaining outstanding customer service. Beyond processing claims, this individual will contribute to improving operational efficiency by identifying process issues, supporting continuous improvement initiatives, and ensuring every claim is handled accurately and consistently.

Proposition
Play an important role in helping members receive accurate and timely health benefits by ensuring claims are processed correctly the first time. Your work directly impacts customer satisfaction, provider relationships, and the financial integrity of the organization.
Develop expertise in health insurance, claims adjudication, benefit interpretation, regulatory compliance, multiple processing systems, and healthcare operations while gaining exposure to increasingly complex claim types and business processes.
This opportunity is ideal for someone who enjoys detailed analytical work, solving problems independently, working in a structured environment, and consistently achieving measurable quality and productivity goals while providing outstanding service to members and providers.

Objectives
1. Process Claims Accurately and Efficiently
Within the first 90 days, independently process multiple claim types across assigned lines of business while consistently meeting established departmental standards for quality, productivity, accuracy, timeliness, and dependability. Investigate claims thoroughly, apply contract benefits correctly, resolve edits and exceptions, and maintain complete documentation supporting all processing decisions. Success will be measured through production metrics, audit accuracy, turnaround times, and adherence to departmental quality standards. AI-assisted productivity and documentation tools may be used where appropriate while ensuring all claim decisions comply with company policies and regulatory requirements.

2. Deliver Exceptional Customer Service Through Accurate Claims Resolution
Develop the knowledge and confidence to communicate claims decisions clearly and professionally with members, providers, and internal business partners. Research inquiries, explain claims processing procedures, and resolve issues efficiently while maintaining confidentiality and professionalism. Success will be measured through responsiveness, accuracy of information provided, stakeholder satisfaction, and effective issue resolution.

3. Demonstrate Sound Judgment While Managing Complex Claims
Within the first six months, successfully process increasingly complex claim types by applying critical thinking, investigating supporting documentation, interpreting benefit contracts, and making appropriate adjudication decisions. Escalate issues appropriately while maintaining ownership of assigned work. Success will be measured through audit results, reduction in processing errors, and the ability to independently manage a broad range of claim scenarios.

4. Contribute to Operational Excellence and Continuous Improvement
Throughout the assignment, identify opportunities to improve documentation, workflows, processing accuracy, and system utilization while adapting to changing business priorities, procedures, and regulatory requirements. Participate in special projects, support inventory management, and contribute ideas that improve operational efficiency and service quality. Success will be measured through adaptability, participation in improvement initiatives, process compliance, and contributions that enhance departmental performance.

Subtasks
1. Investigate and Process Medical Claims
Review incoming claims for completeness, validate supporting information, interpret applicable benefit contracts, and process claims accurately within established turnaround times while maintaining required productivity standards.

2. Apply Contract Benefits and Resolve Processing Exceptions
Analyze edits, warnings, eligibility information, pricing, coordination of benefits, and contract provisions to ensure accurate adjudication while resolving exceptions and identifying discrepancies requiring additional investigation.

3. Research, Review, and Reprocess Claims
Investigate previously adjudicated claims, perform corrections when appropriate, verify pricing calculations, and maintain complete audit trails that support future claim reviews and regulatory compliance.

4. Support Members, Providers, and Internal Business Partners
Respond professionally to inquiries by explaining claims decisions, processing procedures, and benefit application while maintaining confidentiality and delivering excellent customer service.

5. Maintain Compliance and Processing Quality
Follow departmental policies, processing guidelines, privacy requirements, attendance expectations, and quality standards while maintaining accurate documentation and supporting successful audit outcomes.

6. Support Team Performance and Continuous Improvement
Adapt to changing workloads, learn new procedures quickly, participate in training, provide feedback on documentation and systems, and contribute to initiatives that improve claims processing efficiency and operational effectiveness.

7. Continuously Evaluate and Integrate AI to Improve Performance
Within the first 90–180 days, identify opportunities to responsibly leverage AI and automation to improve documentation, knowledge retrieval, workflow organization, quality reviews, and productivity while ensuring all claims decisions remain compliant with company policies, regulatory requirements, and human review standards. Evaluate AI-assisted approaches that reduce administrative effort without compromising accuracy, member privacy, or audit readiness.

Preferred Experience
Successful candidates will typically possess:

• High school diploma or equivalent.
• Approximately two years of office experience, preferably in health insurance claims processing, healthcare administration, or a medical office environment.
• Experience using Microsoft Office applications including Word, Outlook, and Excel.
• Strong keyboarding, data entry, analytical, and mathematical skills.
• Excellent attention to detail and the ability to consistently meet productivity and quality expectations.
• Ability to learn multiple claims processing systems and procedures quickly.
• Experience working independently while collaborating effectively within a team-oriented environment.

Definition of Success
Within the first year, this individual will be recognized as a dependable Claims Production Professional who consistently meets or exceeds quality and productivity expectations, accurately processes multiple claim types with minimal supervision, provides exceptional service to members and providers, adapts quickly to changing priorities, and contributes to continuous improvement initiatives that strengthen the efficiency and effectiveness of the Claims Operations team.