Teams at WPS Health Solutions

Evaluate medical necessity and appropriateness of services using evidence-based criteria; review prior authorization requests; authorize services or refer questionable cases to Medical Directors; document case summaries; monitor utilization management queue and productivity; analyze utilization trends; collaborate with cross-functional teams; ensure compliance with policies, regulatory and URAC standards; train new nursing staff and recommend process improvements.

Lead enterprise cyber risk, governance, compliance, and assurance. Define risk frameworks, control ownership, and assurance practices; oversee POA&M governance, security awareness, automation and AI cyber enablement; support M&A cyber risk; manage audits, regulatory readiness, GRC tooling, and executive-level risk reporting while developing staff and cross-functional alignment.

Process TRICARE/MVH overseas claims from receipt to resolution, including coordination of benefits, DEERS eligibility checks, claim development, code selection (ICD/CPT/HCPCS), research with external contacts, and patient/sponsor file updates while meeting quality standards and metrics.