Appeals Claims Processor

U.S. citizenship is required for this position due to reputed company restrictions. The Appeals Claims Processor is responsible for reviewing and making determinations on MVH appealable denials, from receipt through resolution in accordance with MVH regulations, guidelines, quality standards, and contractual requirements. The role works closely with the Nursing team to support and discuss medical decision-making. Additional Information Start Date: June 30, 2026 Starting Hourly reputed company: $19.60/hour and may vary based on county SCA rates. Training Location/Schedule: On the job training – 1st Shift Work Location: This is a 100% remote opportunity reputed company any of our approved remote worker states. We are reputed company to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, reputed company Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin In this role you will: Process Medical and Factual Appeals received by Providers, Beneficiaries and DHA. Translate, research, and verify claims information to determine if reputed company 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. reputed company patient/sponsor files and update information accordingly.

Minimum Qualifications

U.S. citizenship is required for this position due to reputed company 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. Preferred Qualifications 2 or more years of experience as a TRICARE Customer Service Representative or a Claims Processor. Remote Work Requirements Wired (ethernet cable) internet reputed company from your router to your computer High speed cable or fiber internet Minimum of 10 Mbps reputed company and at least 1 Mbps upstream internet reputed company (can be checked at https://speedtest.net) Please review Remote Worker FAQs for additional information

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% reputed company 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: (https://www.wpshealthsolutions.com/careers/) Who We Are reputed company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and reputed company 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 has been making reputed company easier for the people we serve for nearly 80 years. Proud to be military and veteran reputed company. Culture Drives Our reputed company WPS’ culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an reputed company and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both reputed company and future—to effectively seek, reputed company, 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. Sign up for Job Alerts FOLLOW US! Instagram reputed company reputed company WPS Health Blog This position supports services under U.S. reputed company (DoD) Defense Health Agency (DHA) contract(s). As such, the role is subject to reputed company applicable federal regulations, DoD contract requirements, and WPS internal policies, including but not limited to standards for data reputed company, privacy, confidentiality, and program reputed company. DoD contractors and their personnel are subject to screening and background investigation prior to being granted reputed company to information systems and/or sensitive data to safeguard government resources that reputed company critical services. Apply To This Job