Note: The job is a remote job and is open to candidates in USA. WPS is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. The Appeals Claims Processor is responsible for reviewing and making determinations on MVH appealable denials, working closely with the Nursing team to support medical decision-making.

Responsibilities

• Process Medical and Factual Appeals received by Providers, Beneficiaries and DHA
• Translate, research, and verify claims information to determine if all requirements have been met
• Accountable for CNOTE completion, Summary Log creation, calculation of amounts in dispute, and sending determination letters
• Review incoming Appeals mail to ensure it is being submitted to the appropriate team
• Initiate adjustments, reprocesses and serve as resource for other teams
• Access patient/sponsor files and update information accordingly

Skills

• U.S. citizenship is required for this position due to Department of Defense restrictions
• High School Diploma or GED or equivalent experience
• 1 or more years of experience in a claims processing role
• Knowledge of TRICARE Policy Manuals and eligibility guidelines, claims adjudication procedures and MVH system programs
• Ability to effectively utilize available resources to further research and verify claims
• Strong written communication skills
• Demonstrates the ability to work independently and take initiative
• 2 or more years of experience as a TRICARE Customer Service Representative or a Claims Processor

Benefits

• Remote 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

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