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Medicare Claims Representative (Hybrid - West Frankfort, IL)

WPS Health Solutions
dental insurance, paid time off, 401(k), remote work
United States, Illinois, West Frankfort
1000 Factory Outlet Boulevard (Show on map)
Jul 28, 2025
Description Role Snapshot Our Medicare Claims Representative processes Medicare claims from receipt through resolution in accordance with applicable policies, procedures, and regulatory requirements. This role ensures timely and accurate claim resolution while maintaining high standards for quality and customer service. Hourly Rate of Pay $18.50/hour or more based on county SCA rates. Training Location/Schedule: Mandatory phased training from Monday through Friday will be required over the first 8 months. The first 3-week training sessions will be Monday-Friday from 7:30am - 4:00pm. (Subsequent 3-week training sessions will be planned and Monday-Friday from 7:30am - 4:00pm, dates to be provided.) Scheduled Shift: Flexible schedule once trained, 8-hours shifts between 6:00 am-6pm CST, (Available in-between 2-3-week training modules and once fully trained) split shift is an option. Hybrid Work Location This position will be hybrid, having the regional availability to come in our office two days a week cadence or as needed for training and work. Our office location: West Frankfort Office 1000 Factory Outlet Boulevard West Frankfort, IL 62896. Onsite work will be tailored for team cohesion, strategy, planning and collaboration. How do I know this opportunity is right for me? If you: Can review Medicare Part A and Part B claims, this includes complex and specialty claims, and by applying federal and internal guidelines to ensure appropriate application of processing guidelines, payment rules, and manual calculation procedures. Would enjoy handling complex adjustments involving multiple admissions and adjustments regarding pending returned notices and manually adjust reconsideration, including patient complaints and denials, and process through the system accordingly. Can communicate with internal departments, healthcare providers, and members to obtain additional information or clarify claim issues. Could interact with providers by phone to resolve pending claim problems, correspond with providers, other contractors, and third party billing support entity (s) on various claim-related problems. Would like to assist the claims department in meeting CMS performance metrics and minimum quality and quantity standards. Would enjoy supporting the claims department and provide back-up for completing staff responsibilities as needed. Can keep up to date with changes in regulations, coding standards, and plan policies. Can meet requirements of Federal Privacy Act, International Organization of Standards (ISO 9000), Freedom of Information, Desk Disclosure Reference, and WPS conflict of interest and confidentiality. What will I gain from this role? Enjoying a flexible schedule. Receiving valuable opportunities for knowledge-sharing with seasoned teammates and trainers. Gaining valuable skillsets with many career growth opportunities within the organization. Experience working in an environment that serves our Nation's military, veterans, Guard and Reserves and Medicare beneficiaries. Working in a continuous performance feedback environment. Minimum Qualifications High School Diploma or GED or equivalent experience. 1 or more years of experience in hospital, clinic and/or medical office billing. 1 or more years of post-high school education or coursework in insurance or medical-related studies 1 or more years of experience in a position using computer, keyboarding, and customer communications. Demonstrated proficiency in data entry with a strong ability to maintain focus and accuracy. Ability to multitask, prioritize, problem-solve, and effectively adapt to a fast-paced environment. Ability to work independently and meet quality and production standards. Preferred Qualifications Previous health/Medicare adjudication experience. Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims. Familiarity with medical terminology, procedure and diagnosis codes. 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 (can be checked at https://speedtest.net) Please review Remote Worker FAQs for additional information Benefits Remote and hybrid 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 Professional and Leadership Development Programs Review additional benefits: (https://www.wpshealthsolutions.com/careers/fulltime_benefits.shtml) 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. Sign up for Job Alerts FOLLOW US! Instagram LinkedIn Facebook WPS Health Blog *This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS 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 Disabilities This 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.