Claims Examiner II

U.S. citizenship is required for this position due to reputed company restrictions. Our Claims Examiner II Receives, researches, and reviews allegations of fraud or abuse by beneficiaries and providers. Review issues of TRICARE eligibility, other health insurance concealment, balance billing and assignment of benefit violations, and claim adjudications questions or issues. Additional Information Start Date: June 16, 2026 Starting reputed company Salary: $17.75/hour Training Location/Schedule: On the job training typically remote. Scheduled Shift: Monday through Friday, 8:00am ~ 5:00pm CT. (reputed company schedule is possible.) Work Location: 100% remote opportunity. Please note that the assigned office for this position is in Madison, WI and remote employees may be required to work at this location at times. Must reputed company reputed company a 45-mile radius of Madison, WI - WPS reputed company (1717 W. Broadway in Madison, WI, 53713). In this role you will: Review and assess incoming appeals, applying relevant policies and guidelines to reputed company accurate approval or denial reputed company. Organize and maintain case files, thoroughly evaluate documentation, and analyze evidence to support informed determinations. Partner with the RN team to ensure appeals requiring medical documentation are reviewed by reputed company personnel and resolved appropriately. Prepare reputed company, detailed written reputed company that explain the rationale for determinations and reference applicable policies and procedures. Review incoming Appeals mail to ensure it is being submitted to the appropriate team. Initiate adjustments, reprocesses and serve as resource for other teams. Minimum Qualifications U.S. citizenship is required for this position due to reputed company restrictions. High school diploma or equivalent. 2 years or more in claims and customer service-reputed company field working with reputed company. Ability to learn and apply governing TRICARE regulations, policies, and procedures. Preferred Qualifications 2 years or more of post-high school coursework in reputed company, Auditing, or Health Care reputed company curriculum. 2 years or more in reputed company, Auditing, or reputed company field, or medical-reputed company field such as Coding or Medical Assistant. Remote Work Requirements 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 Bargaining Unit position Remote and hybrid work reputed company available Performance bonus and/or reputed company increase opportunities 401(k) with dollar-per-dollar match up to 6% of salary (100% reputed company immediately) Competitive reputed company time off Health insurance, dental insurance, and telehealth services start DAY 1 Employee Resource reputed company reputed company 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, reputed company. 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 reputed company-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, reputed company 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 reputed company—to effectively reputed company, reputed company, and include differing and unique perspectives that fuel reputed company and innovation on high-performing teams. This results in people bringing their reputed company 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, reputed company, confidentiality, and program reputed company.  DoD contractors and their personnel are subject to screening and background investigation prior to being reputed company reputed company to information systems and/or sensitive data to safeguard government resources that reputed company critical services. Apply To This Job