Appeals Registered Nurse

WPS Health Solutions; Columbus (OH); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote work options

Performance bonus

401(k) with generous match

Paid time off

Health insurance

Dental insurance

Telehealth services

Professional development

Job summary

WPS Health Solutions in Columbus, OH, is seeking an Appeals Nurse to review medical records and Medicare claims for first-level appeals to determine medical necessity and coverage alignment.

The role collaborates with Appeals Examiners to prepare timely redeterminations, document clinical rationales, and ensure compliance with CMS guidelines. A registered nurse with strong communication and attention to detail is essential for success in this fast-paced environment.

Qualifications

• Active RN license in good standing in state of practice.
• ASN or BSN degree required.
• 1+ year clinical experience in a healthcare setting.
• Excellent written and verbal communication.
• Strong attention to detail and multi-case organization.

Responsibilities

• Review first-level appeal cases and ensure medical documentation supports the appeal.
• Perform medical record reviews to determine clinical necessity and provide recommendations.
• Prepare and submit written appeal letters with rationales and evidence.
• Ensure timely follow-up and resolution per policies and CMS requirements.
• Stay updated on healthcare laws and CMS regulations relevant to appeals.

Skills

Communication skills

Clinical judgment

RN license

Detail-oriented

MS Office suite

Education

ASN or BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

Role Snapshot

The Appeals Nurse examines medical records and claims information for first-level appeal cases to determine whether services provided were medically necessary and meet Medicare coverage guidelines in accordance with Medicare regulations and policies. The Appeals RN works in collaboration with the Appeals Examiners/Reps to ensure redeterminations are medically reviewed as needed and completed timely.

Salary Range

66-68k

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

Work Location

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

How do I know this opportunity is right for me? If you are interested in the following activities:

• Review and assess first-level appeal cases for denied services, ensuring all relevant medical documentation, coding, and clinical information are provided to support the appeal.
• Conduct comprehensive medical record reviews to determine the clinical necessity of services and make recommendations for resolution based on clinical guidelines, policy, and the medical necessity of care.
• Prepare and submit written appeal letters, including comprehensive rationales and supporting clinical evidence.
• Ensure timely follow-up on all appeals and ensure proper resolution is reached in accordance with company policies and external regulations.
• Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process, ensuring all actions comply with regulatory and contractual requirements.
• Work with and provide directions to Redetermination Representatives to ensure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards.

Minimum Qualifications

• Associate's (ASN) or Bachelor's Degree in Nursing (BSN).
• Active RN license, applicable to state of practice in good standing.
• One (1) or more years of clinical experience in a healthcare setting (hospital/bedside, case management, MDS/Skilled Nursing, etc.).
• Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
• Strong attention to detail and organizational skills to manage multiple cases simultaneously.
• Basic knowledge and understanding of medical/clinical review processes (i.e., Appeals/Utilization Review).
• Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.

Preferred Qualifications

• Experience working for a Medicare Administrative Contractor (MAC) preferred.
• One (1) or more years of experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals preferred.
• Basic Medicare knowledge and/or experience preferred.

Remote Work Requirements

• Wired (ethernet cable) internet connection from your router to your computer.
• High speed cable or fiber
• 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/)

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.

Medicare (GHA)

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

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.