REMOTE Medical Review Nurse Examiner (LPN) - Must live within vicinity of Madison, WI campus location

Who We Are

WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in 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 Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready. **

Culture Drives Our Success**

WPS’ Performance-Based Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive and empowering employee experience. We recognize the benefits of Diversity, Equity, and Inclusion as an investment in our workforce—both current and future—to effectively seek, leverage, and include diverse 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.

From 2021 to 2023, WPS Health Solutions was recognized for several awards:

• Madison, Wisconsin’s Top Workplaces
• USA Top Workplaces and the cultural excellence awards for Remote Work and Work-Life Flexibility
• Achievers 50 Most Engaged Workplaces® with the further honor of Achievers “Elite 8” winner in the category of Culture Alignment
• DAV Patriot Employer
• VETS Indexes 4 Star Employer
• BBB Torch Award for Ethics from Better Business Bureau of Wisconsin

Role Snapshot

Role

This role will perform review of high dollar, unusual, or complex cases to determine coverage, medical necessity, and frequency of services in accordance with MVH policies. This includes:

• Apply medical knowledge to determine proper level of payment on unusual or complex cases and process claims in accordance with processing guidelines and MVH regulations.
• Initiate correspondence to providers and beneficiaries to obtain additional information needed to complete medical review of claims.
• Assist in training new employees.
• Prepare cases for medical advisors and outside consultants.
• Complete pricing reviews utilizing provider file and procedure fee file to determine allowed amounts.
• Initiate recoupments or adjustments as needed.
• Perform retrospective reviews utilizing psychiatric and medical review criteria sets.
• This job profile is not intended to be an exhaustive list of all duties or responsibilities associated with the job. Other job-related duties may be assigned.

How do I know this opportunity is right for me? If you:

• Communicate with confidence, clarity, and sound reasoning when discussing concerns, ideas, and suggestions with all levels of staff and management
• Are technically sound on the computer and have worked with applications such as MS Outlook, Teams, and Excel
• Excel at critical thinking and can make evidenced based decisions

What will I gain from this role?

• Working in an innovative and process improvement minded environment that champions change
• Working in a continuous performance feedback environment
• Experience working in an environment that serves our Nation’s military, veterans, Guard and Reserves and Medicare beneficiaries

Minimum Qualifications

• Must live within vicinity of Madison, WI campus location
• U.S. citizenship is required for this position due to Department of Defense restrictions
• Licensed Practical Nursing Degree
• Licensed Practical Nurse (government mandate)
• One (1) or more years of clinical experience
• Ability to apply medical knowledge to high dollar, unusual, or complex claims in determining medical necessity and frequency of services
• Ability to learn Military and Veterans Health (MVH) claims processing procedures, regulations, policies, and automated system functions

Preferred Qualifications

• Focused experience with surgical procedures and utilization review

Remote Work Requirements

• 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

Additional Information

• Anticipated Start Date: 11/27/23
• Base Pay: $19.35/hour
• Scheduled Shift: Monday through Friday, 8:00 AM to 4:00 PM Central Standard Time with potential for voluntary and scheduled overtime based on business need.
• # of Positions: 1

Benefits

• Bargaining Unit position
• Performance bonus and/or merit increase opportunities
• 401(k) with dollar-per-dollar match up to 6% of 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 here

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