Job Information
WPS Health Solutions MVH Priority Claims Representative – $18.00/hr, (Must live in vicinity of Madison, WI WPS campus) in Madison, Wisconsin
Description
Role Snapshot:
Respond to inquiries from beneficiaries, providers, government agencies, and other affiliated representatives or groups regarding eligibility, benefit determination, billing, and claims adjudication questions or problems. Establish and maintain rapport with contacts and present a favorable corporate image while responding to inquiries within timeframes required to exceed contractual standards. Support processing of claims for assigned Military and Veterans Health (MVH) contract from receipt through resolution in accordance with regulations, guidelines and quality standards with expertise in coordination of benefits (COB), eligibility, authorization, and claims development.
Additional Information:
Start Date: April 21st, 2025
Starting Base Pay: at least $18.00 per hour
Training Schedule: On the job Training
Scheduled Shift: Monday through Friday, Second Shift, 9:25am-6:00pm CT
Work Location: 100% remote opportunity. Please note that the assigned office for this position is in Madison, WI and remote employees may be required to work at this location at times.
Job Responsibilities
Customer Service (60%)
Research and respond to telephone and written inquiries, which may include inquiries referred to executive staff/management or directly from government partners, concerning eligibility, benefits, problems in claims filing and adjudication and billing questions.
Apply appropriate provisions of MVH regulations, interpretations, and procedural directives to make determinations on eligibility and benefits in drafting appropriate responses to inquiries.
Communicate with inquirer to determine appropriate authorization or referral of services.
Obtain development information from external contacts and add successful development information to claim.
Handle escalated inquiries from prime partner and government.
Deal tactfully with people in a wide variety of situations to convey a favorable corporate image.
Claims Processing (40%)
Collect and record data for documentation and analysis.
Process claims from receipt through resolution in accordance with regulations, guidelines, and quality standards.
Obtain and analyze claims data to determine specific problem area, including external communications to obtain data.
Review submitted claim information and select correct procedure and/or diagnosis code(s) using manuals (e.g., ICD-10, CPT4, HCPCS).
Create and update all computer files for patient/sponsor screens, eligibility, Defense Enrollment Eligibility Reporting System (DEERS), authorization and Other Health Insurance (OHI) information.
Update computer screens to payment levels for payable services.
Correct claim information and adjudication errors throughout every process and adjustment applications.
Determine medical review referral of claims based on contract requirements and diagnoses.* This job profile is not intended to be an exhaustive list of all duties or responsibilities associated with the job. Other job-related duties may be assigned.
Minimum Qualifications:
High school diploma or equivalent Required
Two (2) years or more of MVH claims processing and call center experience
Working knowledge of medical and insurance terminology
Knowledge of claims regulations, benefits, procedures, and online systems
Preferred Qualifications:
- Knowledge of provider coding and edit resolution
Remote Work Requirements
Wired (ethernet cable) internet connection from your router to your computer
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)
Benefits
Bargaining Unit position
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
Review additional benefits here (https://www.wpshealthsolutions.com/careers/fulltime_benefits.shtml)
Who We Are
WPS Health Solutions (https://www.wpshealthsolutions.com/about/index.shtml) 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 (https://www.wpshealthsolutions.com/75/) . 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 (https://www.wpshealthsolutions.com/news/?c=awards)
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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)