Appeals Claims Rep - Redeterminations

Role Snapshot
Our Appeals Claims Rep (Redetermination Representative) responds to requests for first-level appeals. Reviews and compares processed claims with edit/audit detail and Medicare Policy. Refers cases to appeal nurses for medical necessity determination. Reviews medical documentation and claims history for frequency of service, required coding elements, and accurate fee determinations. Completes decision letters or claim adjustments as required to effectuate first level of appeal decisions. Establishes and maintain a professional rapport with contacts and present a favorable corporate image.

Additional Information

• Start Date: Tuesday, March 24, 2026
• Starting Base Pay: $19.05/hour or more based on county SCA rates.
• Training Schedule: First 4 Weeks Monday through Friday, 7:30am-4:05pm CST
• Scheduled Shift: Flexible schedule once trained, 8-hours shifts between 6:00am-6:00pm CST

Remote Work:
We are open to remote work in the following approved states:
Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin

In this role you will:

• Review and respond to customer requests by providing written Medicare Redetermination Notices (MRNs) in the first step of the Medicare appeal process.
• Apply knowledge of Medicare regulations, claims processing, and appeal guidelines to resolve requests accurately and efficiently.
• Review system and hard copy documentation, including medical notes, to assess medical necessity, service frequency, and correct fee determinations.
• Refer cases to appeal nurses when clinical judgment is needed or required by audit.
• Adjudicate redetermination decisions by resolving error edits, audits, coding discrepancies, allowable amounts, and pending requests, ensuring full claim resolution.
• Determine financial liability and ensure proper documentation of decision explanations in MRN letters using templates and input from medical staff.
• Utilize various technological tools to draft and revise determination notifications.
• Resolve pended or aged cases, log all requests, and document actions taken in online comment files.
• Research electronic redetermination work processes and reference manuals to support decision-making.
• Correspond with Medicare customers to clarify claim details and explain adjudication outcomes.
• Educate providers on Medicare regulations and guidelines to ensure correct claim submissions, referring recurrent errors to Provider Education for follow-up.
• Identify, verify, and process overpayment situations, assisting in reporting and recoupment efforts.
• Identify and report potential fraudulent activities involving providers and beneficiaries to Complaint Screening.
• Redirect misdirected correspondence and unusual claims issues to the appropriate department for further action.
• Assist in meeting CMS performance metrics and quality standards, providing backup support as needed.
• Provide technical assistance by reporting system issues, testing enhancements, and supporting system changes.

Minimum Qualifications

• Must have lived in the United States 3 out of the last 5 years prior to submitting an application.
• High School Diploma or GED or equivalent experience.
• 1 or more years of experience in a claims processing role.
• Demonstrated proficiency in data entry with a strong ability to maintain focus and accuracy.
• Ability to multitask, prioritize, problem-solve, and effectively adapt to a fast-paced environment.
• Ability to work independently and meet quality and production standards.

Preferred Qualifications

• 2 or more years recent health insurance experience (customer service, claims processing, or medical billing) dealing with coverage and medical necessity determinations.

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)
• 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% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Professional and Leadership Development Programs
• Review additional benefits: (https://www.wpshealthsolutions.com/careers/)

Who We Are

WPS, a health solutions 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 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 has been making healthcare easier for the people we serve for nearly 80 years. 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.

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This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services