Remote Appeals Nurse: Medicare Case Review Specialist
WPS—A health solutions company
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Benefits offered by this job
Job summary
WPS—A health solutions company is seeking an Appeals RN to review medical records and claims for first-level appeal cases, ensuring services were medically necessary and compliant with Medicare guidelines. The role collaborates with Appeals Examiners to support timely redeterminations.
Responsibilities include drafting persuasive appeal letters, coordinating with redetermination teams, and staying current with healthcare laws.
Qualifications
- Associate's or Bachelor's degree in Nursing (ASN/BSN).
- Active RN license in good standing.
- 1+ year clinical experience in healthcare setting.
- Strong written and verbal communication skills.
Responsibilities
- Review first-level appeal cases for medical necessity.
- Conduct medical record reviews to assess clinical necessity and guideline adherence.
- Prepare and submit written appeal letters with rationales and evidence.
- Ensure timely follow-up and resolution in line with policies and regulations.
- Stay updated on healthcare laws and CMS requirements.
- Coordinate with Redetermination Representatives to meet CMS timelines.
Skills
Education
Tools
Job description
WPS—A health solutions company is seeking an Appeals RN to review medical records and claims for first-level appeal cases, ensuring services were medically necessary and compliant with Medicare guidelines. The role collaborates with Appeals Examiners to support timely redeterminations.
Responsibilities include drafting persuasive appeal letters, coordinating with redetermination teams, and staying current with healthcare laws.
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