WI3641512

1

Vocational Degree

Associate Degree

Unspecified

40

JOB REQUIREMENTS: Description Who We Are 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 . 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
inclusive and empowering employee experience. We recognize the benefits
of Diversity, Equity, and Inclusion as an investment in our
workforce-both current and future-to effectively seek, leverage, and
include diverse 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. From 2021 to 2023, WPS Health
Solutions was recognized for several awards: Role Snapshot Our Appeals
Nurse will examine medical records and claims information for
first-level appeal cases to determine whether services provided were
medically necessary and meet Medicare coverage guidelines in accordance
with Medicare regulations and policies. In addition, this role will:
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 appeals 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. How do I know this opportunity is right
for me? If you: Have moved away from direct patient care and want to
continue using your nursing knowledge in a new and different way. Excel
at analyzing information and critical thinking to make sound medical
decisions. Are highly organized and adept at researching and finding
answers independently using all available resources. Thrive in a
production environment where quality and\... For full info follow
application link. Wisconsin Physicians Service Insurance Corporation is
an Equal Opportunity Employer/Protected Veterans/Individuals with
Disabilities employer. \*\*\*\*\* APPLICATION INSTRUCTIONS: Apply
Online: ipc.us/t/4252957FCC554B29 Qualified females, minorities, and
special disabled veterans and other veterans are encouraged to apply.