Our Claims Examiner II Receives, researches, and reviews allegations of fraud or abuse by beneficiaries and providers. Review issues of TRICARE eligibility, other health insurance concealment, balance billing and assignment of benefit violations, and claim adjudications questions or issues.
Additional Information
- Start Date: June 16, 2026
- Starting Base Salary: $17.75/hour
- Training Location/Schedule: On the job training typically remote.
- Scheduled Shift: Monday through Friday, 8:00am ~ 5:00pm CT. (Flex schedule is possible.)
- Work Location: 100% remote opportunity. Please note that the assigned office for this position is in Madison, WI and remote employees may be required to work at this location at times. Must reside within a 45-mile radius of Madison, WI - WPS Headquarters (1717 W. Broadway in Madison, WI, 53713).
In this role you will:
- Review and assess incoming appeals, applying relevant policies and guidelines to render accurate approval or denial decisions.
- Organize and maintain case files, thoroughly evaluate documentation, and analyze evidence to support informed determinations.
- Partner with the RN team to ensure appeals requiring medical documentation are reviewed by qualified personnel and resolved appropriately.
- Prepare clear, detailed written decisions that explain the rationale for determinations and reference applicable policies and procedures.
- Review incoming Appeals mail to ensure it is being submitted to the appropriate team.
- Initiate adjustments, reprocesses and serve as resource for other teams.
Minimum Qualifications
- U.S. citizenship is required for this position due to Department of Defense restrictions.
- High school diploma or equivalent.
- 2 years or more in claims and customer service-related field working with public.
- Ability to learn and apply governing TRICARE regulations, policies, and procedures.
Preferred Qualifications
- 2 years or more of post-high school coursework in Accounting, Auditing, or Health Care related curriculum.
- 2 years or more in Accounting, Auditing, or related field, or medical-related field such as Coding or Medical Assistant.
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
Benefits
- Bargaining Unit position
- Remote and hybrid work options available
- 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: (https://www.wpshealthsolutions.com/careers/)
Who We Are
WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, 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 has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.
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. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique 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.
We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.
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This position supports services under U.S. Department of Defense (DoD) Defense Health Agency (DHA) contract(s). As such, the role is subject to all applicable federal regulations, DoD contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. DoD contractors and their personnel are subject to screening and background investigation prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services.
Equal Opportunity Employer/Protected Veterans/Individuals with DisabilitiesThis employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Skills Required
- High school diploma or equivalent
- 2 years or more in claims and customer service-related field working with public
- Ability to learn and apply governing TRICARE regulations, policies, and procedures
What We Do
WPS Health Solutions is celebrating 75 years in business as a highly regarded government contractor and leader in the insurance industry. In 2021, the Wisconsin State Journal named WPS as a Top Workplace in the Madison area. WPS has several divisions committed to delivering high-quality service to our customers. - WPS Health Insurance and WPS Health Plan offer affordable health plans for individuals, small businesses, and large businesses, plus benefits administration. - WPS Government Health Administrators administers Part A and Part B Medicare benefits—services we have provided since the program’s inception—for millions of seniors in multiple states. - WPS Military and Veterans Health serves millions more beneficiaries who are active in the U.S. military, veterans, and their families. - EPIC Specialty Benefits has offered voluntary nonmedical benefits, such as term life, disability, dental, and vision, for more than 35 years. WPS also actively partners with nonprofit organizations to help make lasting changes in the communities we serve, with an emphasis on health issues, especially for military and veterans, women, and children.
