Appeals Claims Processor

U.S. citizenship is required for this position due to Department of Defense 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 Rate: $19.60/hour and may vary based on county SCA rates.
• Training Location/Schedule: On the job training – 1^st Shift
• Work Location: This is a 100% remote opportunity within any of our approved remote worker states.

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:

• Process Medical and Factual Appeals received by Providers, Beneficiaries and DHA.
• Translate, research, and verify claims information to determine if all 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.
• Access patient/sponsor files and update information accordingly.

Minimum Qualifications

• U.S. citizenship is required for this position due to Department of Defense 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 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
•  Employee Resource Groups
• 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 U.S. Department of Defense (DoD) Defense Health Agency (DHA) contract(s).  As such, the role is subject to all applicable federal regulations, DoD contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity.  DoD contractors and their personnel are subject to screening and background investigation prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services.