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 -- 1st 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.

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.

Who We Are

WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. 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.

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.

Note: This position supports services under U.S. Department of Defense (DoD) Defense Health Agency (DHA) contract(s). Personnel are subject to screening and background investigation.