Remote Appeals Nurse — Medicare Case Review Expert

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

Benefits offered by this job

Remote work options

Bonus opportunities

401(k) with match

Health and dental coverage

Job summary

WPS is seeking an Appeals Nurse (RN) to review medical records and denial information for first-level Medicare appeals, ensuring services meet medical necessity and CMS guidelines. You will collaborate with Appeals Examiners to prepare rationales and maintain timely resolutions.

The role requires an ASN/BSN and active RN license with 1+ year of clinical experience, and offers remote work options in approved states, including Michigan.

Qualifications

• ASN or BSN in nursing with active RN license in good standing.
• 1+ year clinical experience in healthcare (hospital/bedside, case management, MDS/Skilled Nursing).
• Clear written and verbal communication skills.
• Strong attention to detail and organization to manage multiple cases.
• Familiarity with medical record reviews or appeals/utilization review.
• Proficient in multiple online systems (MS Outlook/Teams/OneNote/Word/Excel).

Responsibilities

• Review and assess first-level appeal cases for denied services, ensuring all medical documentation supports the appeal.
• Conduct medical record reviews to determine clinical necessity and provide recommendations based on guidelines.
• Prepare and submit written appeal letters with rationales and supporting evidence.
• Ensure timely follow-up on all appeals and proper resolution per policies and CMS regulations.
• Maintain awareness of healthcare laws and CMS policies relevant to appeals.
• Coordinate with Redetermination Representatives to ensure timely responses within CMS standards.

Skills

Clinical documentation

Communication

Attention to detail

MS Outlook

Teams

OneNote

Word

Excel

Education

ASN or BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

WPS is seeking an Appeals Nurse (RN) to review medical records and denial information for first-level Medicare appeals, ensuring services meet medical necessity and CMS guidelines. You will collaborate with Appeals Examiners to prepare rationales and maintain timely resolutions.

The role requires an ASN/BSN and active RN license with 1+ year of clinical experience, and offers remote work options in approved states, including Michigan.