Medicare Claims Representative

WPS is a leading not-for-profit health insurer and federal government contractor. The Medicare Claims Representative processes Medicare claims from receipt through resolution, ensuring timely and accurate claim resolution while maintaining high standards for quality and customer service. Responsibilities Review Medicare Part A claims, including complex and specialty claims, 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 and 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 third party billing support entities on various claim-related problems Assist the claims department in meeting CMS performance metrics and minimum quality and quantity standards Support the 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 Skills High School Diploma or GED or equivalent experience 1 or more years of experience in hospital, clinic and/or medical office billing 1 or more years of post-high school education or coursework in insurance or medical-related studies 1 or more years of 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 Previous health/Medicare adjudication experience Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims Familiarity with medical terminology, procedure and diagnosis codes Benefits Remote and hybrid 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 Company Overview WPS, a health solutions company, is an independent, not-for-profit, local company based in Madison, Wisconsin. It was founded in 1946, and is headquartered in Madison, Wisconsin, USA, with a workforce of 1001-5000 employees. Its website is