Claims Examiner II

WPS Health Solutions New • Madison, WI

23h • Remote

About The Position

Our Claims Examiner II Receives, researches, and reviews allegations of fraud or abuse by beneficiaries and providers. Review issues of TRICARE eligibility, other health insurance concealment, balance billing and assignment of benefit violations, and claim adjudications questions or issues. This position supports services under U.S. Department of Defense (DoD) Defense Health Agency (DHA) contract(s). As such, the role is subject to all applicable federal regulations, DoD contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. DoD contractors and their personnel are subject to screening and background investigation prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services.

Requirements

• U.S. citizenship is required for this position due to Department of Defense restrictions.
• High school diploma or equivalent.
• 2 years or more in claims and customer service-related field working with public.
• Ability to learn and apply governing TRICARE regulations, policies, and procedures.
• 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 )

Nice To Haves

• 2 years or more of post-high school coursework in Accounting, Auditing, or Health Care related curriculum.
• 2 years or more in Accounting, Auditing, or related field, or medical-related field such as Coding or Medical Assistant.

Responsibilities

• Receives, researches, and reviews allegations of fraud or abuse by beneficiaries and providers.
• Reviews issues of TRICARE eligibility, other health insurance concealment, balance billing and assignment of benefit violations, and claim adjudications questions or issues.
• Reviews and assess incoming appeals, applying relevant policies and guidelines to render accurate approval or denial decisions.
• Organizes and maintains case files, thoroughly evaluates documentation, and analyzes evidence to support informed determinations.
• Partners with the RN team to ensure appeals requiring medical documentation are reviewed by qualified personnel and resolved appropriately.
• Prepares clear, detailed written decisions that explain the rationale for determinations and reference applicable policies and procedures.
• Reviews incoming Appeals mail to ensure it is being submitted to the appropriate team.
• Initiates adjustments, reprocesses and serves as resource for other teams.

Benefits

• Remote and hybrid work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with dollar-per-dollar match up to 6% of 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED