Job Description:

Description

Role Summary:

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.

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, and testing new enhancements and other changes as released.

This role could be a good fit if you:

• Ability to learn and apply Medicare guidelines and computer-based tools


• Knowledge of or ability to learn and apply insurance and medical terminology


• Ability to identify issues, research, and initiate appropriate action


• Want to be rewarded for performance through the Pay for Performance program


• Flexible work schedule

You'll benefit from this experience by:

• Enhanced learning of Medicare guidelines


• Being a part of a successful team that services providers and beneficiaries within the Medicare program.


• Enjoy working within a supportive, high-performing and team-building environment

You need to have:

• 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


• 2 or more years of experience working for the VA contract with WPS


• 2 or more years of experience in customer service or claims processing with WPS


• Coursework in medical terminology or understanding of general medical terminology

Your team:

The Appeals team is a high performing team that works together to achieve CMS expectations. The team exists of a combination of Supervisors, Analysts, Nurses and Representatives. The team works collaboratively to identify efficiencies in workflows and processes for Part A and Part B with the other departments within Government Health Administrators (GHA).

Location: This role is open to considering 100% remote work the following approved states:
Approved States: Arizona, Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, North Dakota, South Carolina, Texas, Virginia, Wisconsin

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.

http://wpshealthsolutions.com/business-units/wpshi.shtml

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.

http://wpshealthsolutions.com/business-units/wpsmvh.shtml

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.

http://wpshealthsolutions.com/business-units/wpsgha.shtml

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.

http://wpshealthsolutions.com/business-units/wpshi.shtml

EPIC Specialty Benefits

EPIC Specialty Benefits provides businesses group insurance products that cover:

• Life


• Disability


• Dental


• Vision


• Voluntary benefits

http://wpshealthsolutions.com/business-units/epicsb.shtml

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