Appeals Registered Nurse

Wisconsin Physicians Service Insurance Corp; Darbydale (OH); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote and hybrid work options

Performance bonus opportunities

401(k) with 100% match for the first 3

Immediate vesting on 401(k)

Job summary

Wisconsin Physicians Service Insurance Corp is seeking an Appeals Nurse to review medical records and claims for first-level appeal cases to determine medical necessity and Medicare compliance.

This RN role collaborates with Appeals Examiners to ensure timely redeterminations, with remote work options in approved states and a salary range of 66,000–68,000 USD per year plus benefits.

Qualifications

• ASN or BSN in Nursing required.
• Active RN license in state of practice in good standing.
• 1+ year of clinical healthcare experience.
• Strong written and verbal communication; detail-oriented.
• Proficient with MS Office Suite.

Responsibilities

• Review and assess first-level appeal cases with proper documentation.
• Conduct medical record reviews to assess clinical necessity.
• Prepare and submit written appeal letters with rationales and evidence.
• Ensure timely follow-up and resolutions per policies and regulations.
• Guide redetermination reps to meet CMS timelines.

Skills

RN license

Communication skills

Attention to detail

Organizational skills

Education

ASN in Nursing

BSN in Nursing

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

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)