Job Description

Our Clinical Manager is accountable to plan, organize, manage, and evaluate clinical operations for Medical Review. This includes developing Centers for Medicare & Medicaid Services (CMS) reports as well as managing activities to ensure accurate rendering of claim decisions. They collaborate with other business areas to ensure WPS and CMS goals and objectives are met utilizing cost-effective, timely, accurate, and innovative methods. This Clinical Manager is accountable to ensure compliance with regulatory and payor guidelines.

Salary Range

$100,000 ~ $120,000

The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

Work Location: Remote OR Hybrid

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

**Employees living within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI) will be expected to be able to come into the office 2 days a week on a regular basis.



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

• Can develop, implement, and maintain the Improper Payment Reduction Strategy (IPRS) for Medical Review.
• Enjoy leading people monitoring and maintaining Full Time Equivalents (FTEs), budget, and workload according to IPRS.
• Thrive when ensuring accurate and timely handling of Medical Review clinical decisions.
• Can monitor all results for Medical Review Accuracy Award Fee, providing follow-up, dispute, and education as indicated.
• Have coordinate with the Medical Review Operations Manager in preparation of the Monthly Status Report.
• Want to ensure effective and timely response to clinical concerns raised by CMS, other CMS contractors and other clinical areas.
• Can maintain detailed knowledge of all Medicare regulations and broad level knowledge of WPS business capabilities.
• Have ensured compliance within federal and state regulations, CMS guidelines, and company policies.
• Enjoy coaching and mentoring the Clinical Med Management team to ensure a culture of accountability and excellence; execute programs to drive employee engagement and satisfaction.

Minimum Qualifications

• Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).
• Active RN license, applicable to state of practice in good standing.
• 5 or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.)
• 3 or more years in a leadership role.
• Extensive knowledge and understanding of CMS guidelines and regulations.
• Extensive knowledge and understanding of medical/clinical review processes.
• Strong analytical, problem-solving, and organizational skills that include:
  • The ability to manage multiple cases simultaneously and meet strict deadlines.
  • Excellent reading comprehension, written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
  • Proficient in Microsoft Office tools with experience working in electronic health records.

Preferred Qualifications

• Experience working for a Medicare Administrative Contractor (MAC).

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
• 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: (

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 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 including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services

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