Claims Representative 2

WPS—A health solutions company; Ohio; Remote; USD 22,000 - 31,000; Full time

Benefits offered by this job

Remote work options available

Performance bonus/merit increases

401(k) with matching

Job summary

WPS, a health solutions company, seeks a Claims Rep 2 to process Medicare claims from receipt to resolution, ensuring timely, accurate handling per policies and regulations. Training begins with on-the-job sessions Monday–Friday, 7:30am–4:00pm CT, with flexible shifts after training.

The role emphasizes quality, customer service, and adherence to CMS guidelines, ISO standards, privacy acts, and confidentiality. Remote work is available in multiple states including Ohio.

Qualifications

• High School Diploma or GED or equivalent experience.
• 1+ year experience in hospital, clinic and/or medical office billing.
• 1+ year post-high school education or coursework in insurance or medical-related studies, with computer, keyboarding and customer communications experience.
• Demonstrated proficiency in data entry with strong focus and accuracy.
• Ability to multitask, prioritize, problem-solve, and adapt to a fast-paced environment.
• Ability to work independently and meet quality and production standards.

Responsibilities

• Review Medicare Part A and Part B claims with guidelines to ensure proper processing and payment rules.
• Handle complex adjustments including reconsideration and patient complaints/denials.
• Communicate with internal departments, providers, and members to obtain information or clarify issues.
• Interact with providers by phone to resolve claim problems; correspond with providers, contractors, and QIOs on issues.
• Assist department in meeting CMS performance metrics and quality standards.
• Support Claims department and back-up staff responsibilities as needed.
• Stay updated with changes in regulations, coding standards, and plan policies.

Skills

Data entry

Multitasking

Customer communication

Attention to detail

Education

High School Diploma or GED

Job description

Role Snapshot

The Claims Rep 2 processes Medicare claims from receipt through resolution in accordance with applicable policies, procedures, and regulatory requirements. This role ensures timely and accurate claim resolution while maintaining high standards for quality and customer service.

Hourly Rate of Pay

• At least $19.00/hour based on county SCA rates.
• On the job training Monday-Friday between 7:30am-4:00pm CT. Cannot miss any time during the training period.
• Scheduled Shift: Flexible schedule once trained, 8-hours shifts between 6am-6pm CT.

Work Location

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.

How do I know this opportunity is right for me? If you enjoy the following:

• Review Medicare Part A and Part B claims including complex and specialty claims, by applying federal and internal guidelines to ensure appropriate application of processing guidelines, payment rules, and manual calculation procedures.
• Handle complex adjustments involving multiple admissions and adjustments regarding pending returned notices. Manually adjust reconsideration, including patient complaints and denials, and process through the system accordingly.
• Communicate with internal departments, healthcare providers, and members to obtain additional information or clarify claim issues.
• Interact with providers by phone to resolve pending claim problems. Correspond with providers, other contractors, and QIOs on various claim-related problems.
• Assist department in meeting CMS performance metrics and minimum quality and quantity standards.
• Support Claims department and provide back-up for completing staff responsibilities as needed.
• Keep up to date with changes in regulations, coding standards, and plan policies.
• Meet requirements of Federal Privacy Act, International Organization of Standards (ISO 9000), Freedom of Information, Desk Disclosure Reference, and WPS conflict of interest and confidentiality.

Minimum Qualifications

• High School Diploma or GED or equivalent experience.
• One (1) or more years of experience in hospital, clinic and/or medical office billing.
• One or more years of post-high school education or coursework in insurance or medical-related studies, and experience in a position using computer, keyboarding, and customer communications.
• 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

• Previous health/Medicare adjudication experience preferred.
• Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims preferred.
• Familiarity with medical terminology, procedure and diagnosis codes preferred.

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.

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.