Claims Rep II

Respond to requests for first level appeals. Review and compare processed claims with edit/audit detail and Medicare Policy. Refer case to appeal nurse for medical necessity determination. Review medical documentation and claims history for frequency of service, required coding elements, and accurate fee determinations. Complete decision letters or claim adjustments as required to effectuate first level of appeal decisions. Establish and maintain a professional rapport with contacts and present a favorable corporate image.

Additional Information:

• Start Date: Tuesday, May 6, 2025
• Starting Base Pay: $17.50 per hour
• Training Schedule: (4 Weeks): Monday through Friday, 7:30am-4:05pm CST
• Scheduled Shift: Flexible schedule once trained, 8-hours shifts between 6:00am-6:00pm CST

Work Location

This role is open to remote work for this opportunity in the following approved states:
Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, Wisconsin

In this role you will:

• Receive, review, and provide written responses (Medicare Redetermination Notice [MRN]) to requests from customers on a post-claim basis in first step of Medicare appeal process.
• Apply knowledge of Medicare regulations, claims processing, and appeal guidelines to determine proper resolution of requests.
• Obtain and review system and hard copy documentation and medical notes. Review and compare processed claims for required coding elements to establish medical necessity, frequency of service, and accurate fee determinations.
• Refer cases to appeal nurses when clinical judgment is required to make decision or is required by audit.
• Determine appropriate resolution to appeal request and adjudicate redetermination decision by resolving all error edits and audits, changing codes, entering allowable amounts, working with other units, pending requests for development, and adjudicating claim to completion.
• Determine appropriate financial liability for decision.
• Develop and complete explanations of decision for MRN decision letter through use of various letter templates, policy information, and input from medical staff.
• Use various technological applications, such as Word, web portal, or electronic letter writing system to generate and revise determination notifications.
• Resolve pended/aged cases, log all requests, and document/update clearly on-line comment file with detail of action taken.
• Research electronic redetermination work processes and reference manuals throughout process of making determinations regarding requests.
• Correspond with Medicare customers to clarify information for claim determination and explain claim adjudication.
• Assist and educate providers on Medicare regulations by utilizing CMS guidelines, publications, and reference materials to ensure correct claim submission. Refer recurrent provider errors to Provider Education for further contact.
• Identify, verify, calculate, and setup overpayment situations. Assist in reporting and recoupment of overpayments.
• Identify and refer potential fraudulent providers and/or beneficiaries to Complaint Screening.
• Refer and forward mis-directed correspondence and unusual claims aberrancies to appropriate area for handling.
• Assist department in meeting CMS performance metrics and minimum quality and quantity standards. Provide back-up for completing staff responsibilities as needed.
• Provide technical assistance by identifying and reporting system problems, testing new enhancements, and other changes as released.

How do I know this opportunity is right for me? If you:

• Are interested in learning and applying Medicare guidelines and computer-based tools
• Have knowledge of or ability to learn and apply insurance and medical terminology
• Enjoy identifying issues, researching, and initiating appropriate actions
• Want to be rewarded for performance through the Pay for Performance program
• Enjoy a flexible work schedule

What will I gain from this role?

• Enhanced learning of Medicare guidelines
• Experience being a part of a successful team that services providers and beneficiaries within the Medicare program.
• Knowledge from working within a supportive, high-performing and team-building environment
• Experience working in an environment that serves our Nation's military, veterans, Guard and Reserves and Medicare beneficiaries
• Working in a continuous performance feedback environment.

Minimum Qualifications

• Must have lived in the United States at least 3 out of the last 5 years - this is a CMS requirement.
• High School diploma or equivalent

We also prefer:

• 2 or more years recent health insurance experience (customer service, claims processing, or medical billing) dealing with coverage and medical necessity determinations

Remote Work Requirements:

• High speed cable or fiber internet
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)
• Please review Remote Worker FAQs for additional information

Benefits:

• Remote and hybrid work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Employee Resource Groups
• Professional and Leadership Development Programs
• Review additional benefits: (https://www.wpshealthsolutions.com/careers/fulltime_benefits.shtml)

Who We Are

WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready.

Culture Drives Our Success

WPS' Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce-both current and future-to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition

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