Remote Appeals Nurse – Medicare Case Review Expert

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

Benefits offered by this job

Remote and hybrid work options

Performance bonus and merit increase

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

Health insurance start DAY 1

Paid time off

Job summary

WPS—A health solutions company is seeking an Appeals Nurse (RN) to review medical records and claims for first-level appeal cases to determine medical necessity under Medicare guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations.

In Illinois and other approved states, you will prepare appeal letters, support clinical evidence, and stay current with healthcare regulations. A BSN/ASN and active RN license are required, with 1+ year of clinical experience.

Qualifications

• ASN or BSN required.
• Active RN license in state of practice.
• 1+ year clinical experience in healthcare.
• Excellent written and verbal communication.
• 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 of services.
• 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 requirements relevant to appeals.
• Provide directions to Redetermination Representatives to meet CMS timelines.

Skills

Written and verbal communication

Attention to detail

Organizational skills

Medical review knowledge

Education

ASN or BSN in Nursing

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

WPS—A health solutions company is seeking an Appeals Nurse (RN) to review medical records and claims for first-level appeal cases to determine medical necessity under Medicare guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations.

In Illinois and other approved states, you will prepare appeal letters, support clinical evidence, and stay current with healthcare regulations. A BSN/ASN and active RN license are required, with 1+ year of clinical experience.