Requisition Number: MEDIC04588
Make determinations whether a denied claim for a certain medical service was reasonable and necessary to pay.
In this role you will:
- Examine medical records and claims information for first-level appeal cases to determine whether services provided were medically necessary or meet Medicare coverage guidelines in accordance with Medicare regulations and policies.
- Utilize clinical knowledge and clinical review judgment to conduct medical review of claim documentation for first-level appeal cases.
- Provide clear and concise written explanations for reason a specific claim or set of claims cannot be paid as a result of first-level redetermination.
- Work with and provide direction to Redetermination Representatives to assure all redeterminations which require a clinical decision are responded to within CMS quality and timelines standards.
- Analyze referrals and identify specific high volume problem issues, and relay information to Redeterminations Manager and Senior Analyst.
- Participate in various workgroups for purposes of Continuous Quality Improvement (CQI) to promote consistent medical review of claim documentation and information.
This role could be a good fit if you:
- Are looking to move away from direct patient care and want to use your nursing knowledge in a new and different way
- Desire day hours with no on-call work, limited weekend work, and enjoy holidays off
- Are technically strong on computers
- Are self-motivated and work with a great degree of independence
You’ll benefit from this experience by:
- Collaborating with a team of both clinicians and non-clinicians
- Understanding Medicare and how the program works
- Learning a variety of systems, including but not limited to, the Medicare Appeal System (MAS) which is the content management system for Part A appeals and our Hyland OnBase tool which is our content management system used for Part B appeals
You need to have:
- Associate’s degree in Nursing
- Active RN license, applicable to state of practice
- 4 years or more of experience in clinical nursing
We also prefer:
- Bachelor’s degree in Nursing and/or related field
- Experience with background in Medicare principles and guidelines
Your team: This team is comprised of clinical staff and operational staff
Compensation and Benefits
- Eligible for annual Performance Bonus Program
- 401(k) with dollar-per-dollar match up to 6% of salary
- Competitive paid time off
- Health and dental insurance start DAY 1
- Vision insurance
- Flexible spending, dependent care, and health savings accounts
- Short- and long-term disability, group life insurance
- Dress for your day
- Innovative professional and cognitive development programs
Who We Are
WPS Health Solutions is an innovator in health insurance and a worldwide leader in claims administration, serving millions of beneficiaries in the United States and abroad.
Founded in 1946, WPS offers health insurance plans for individuals, families, and seniors, and group plans for small and large businesses. We are a world-class claims processor and program administrator for the government’s Medicare program. And we manage benefits for millions of active-duty and retired military personnel and their families.
Learn more about WPS.
Our Purpose and Values
Our purpose is to make healthcare easier for those we serve. Click Here
Our values – Customer Focused, Individual Responsibility, Mutual Respect, and Driven & Passionate – are the core of who we are and how we conduct business every day.
WPS Health Insurance
WPS Health Insurance offers high-quality health insurance plans for individuals and families, Medicare supplement plans for seniors, and group health plans for businesses of every size.
Military and Veterans Health
WPS Military and Veterans Health administers claims and provides customer service and related activities for the U.S. Department of Defense and the U.S. Department of Veterans Affairs and their beneficiaries.
Government Health Administrators
WPS Government Health Administrators manages Medicare Part A and Part B benefits for more than 7 million beneficiaries. As one of the largest contractors for the Centers for Medicare & Medicare Services, we’ve served Medicare beneficiaries and their health care providers since 1966.
WPS Health Plan
WPS Health Plan offers Health Maintenance Organization and Point-of-Service plans to the group and individual markets in eastern and north-central Wisconsin, plus third-party administrator services.
EPIC Specialty Benefits
EPIC Specialty Benefits provides businesses group insurance products that cover:
- Voluntary benefits
Stay connected: Sign up for Job Alerts