Medicare Appeals RN — Remote, Growth & Benefits

WPS—A health solutions company; Virginia; Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote and hybrid work options

Performance bonus

401(k) with match

Paid time off

Health insurance

Job summary

WPS is seeking an Appeals Nurse (RN) to review medical records and claims for first-level appeal cases to determine medical necessity and compliance with Medicare coverage guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and adherence to CMS standards.

The position offers a remote-friendly environment with a salary range of 66,000–68,000 USD per year, with flexibility based on experience and qualifications.

Qualifications

• ASN or BSN nursing degree.
• Active RN license in good standing in the applicable state.
• 1+ year of clinical experience in a healthcare setting.
• Excellent written and verbal communication skills.
• Strong attention to detail and organizational skills.
• Basic knowledge of medical/clinical review processes.
• Proficient with MS Outlook, Teams, OneNote, Word and Excel.

Responsibilities

• Review and assess first-level appeal cases for denied services.
• Conduct medical record reviews to determine clinical necessity and provide recommendations.
• Prepare and submit written appeal letters with comprehensive rationales and evidence.
• Ensure timely follow-up on all appeals and proper resolution per policies and regulations.
• Maintain awareness of healthcare laws and CMS contract requirements.
• Coordinate with Redetermination Representatives to meet CMS timelines.

Skills

Communication skills

Attention to detail

Medical review processes knowledge

MS Office proficiency

Clinical experience

Education

ASN or BSN

Tools

MS Outlook

Microsoft Teams

OneNote

Word

Excel

Job description

WPS is seeking an Appeals Nurse (RN) to review medical records and claims for first-level appeal cases to determine medical necessity and compliance with Medicare coverage guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and adherence to CMS standards.

The position offers a remote-friendly environment with a salary range of 66,000–68,000 USD per year, with flexibility based on experience and qualifications.