JOB REQUIREMENTS: Description Who We Are is a leading not-for-profithealth insurer and federal government contractor headquartered inWisconsin. WPS offers health insurance plans for individuals, families,seniors, and group health plans for small to large businesses. Weprocess claims and provide customer support for beneficiaries of theMedicare program and manage benefits for millions of active-duty andretired military personnel across the U.S. and abroad. WPS HealthSolutions has been making health care easier for the people we serve formore than . Proud to be military and veteran ready. Culture Drives OurSuccess WPS\' Performance-Based Culture is where the great work andinnovations of our people are seen, fueled, and rewarded. We accomplishthis by creating an inclusive and empowering employee experience. Werecognize the benefits of Diversity, Equity, and Inclusion as aninvestment in our workforce-both current and future-to effectively seek,leverage, and include diverse perspectives that fuel agility andinnovation on high-performing teams. This results in people bringingtheir authentic selves to work every day in an organization thatsuccessfully adapts to business changes and new opportunities. From 2021to 2023, WPS Health Solutions was recognized for several awards: RoleSnapshot This role will perform review of high dollar, unusual, orcomplex cases to determine coverage, medical necessity, and frequency ofservices in accordance with MVH policies. This includes: Apply medicalknowledge to determine proper level of payment on unusual or complexcases and process claims in accordance with processing guidelines andMVH regulations. Initiate correspondence to providers and beneficiariesto obtain additional information needed to complete medical review ofclaims. Assist in training new employees. Prepare cases for medicaladvisors and outside consultants. Complete pricing reviews utilizingprovider file and procedure fee file to determine allowed amounts.Initiate recoupments or adjustments as needed. Perform retrospectivereviews utilizing psychiatric and medical review criteria sets. * Thisjob profile is not intended to be an exhaustive list of all duties orresponsibilities associated with the job. Other job-related duties maybe assigned. How do I know this opportunity is right for me? If you:Communicate with confidence, clarity, and sound reasoning whendiscussing concerns, ideas, and suggestions with all levels of staff andmanagement Are technically sound on the computer and have worked withapplications such as MS Outlook, Teams, and Excel Excel at criticalthinking and can make evidenced based decisions What will I gain fromthis role? Working in an innovative and process improvement mindedenvironment that... For full info follow application link. WisconsinPhysicians Service Insurance Corporation is an Equal OpportunityEmployer/Protected Veterans/Individuals with Disabilities employer.***** APPLICATION INSTRUCTIONS: Apply Online:ipc.us/t/0B417094E01547F1 Qualified females, minorities, and specialdisabled veterans and other veterans are encouraged to apply.