Remote Appeals Nurse: Medicare Medical Necessity Expert

WPS Health Solutions; Atlanta (GA); Remoto; USD 66.000 - 68.000; Tempo integral

Benefícios oferecidos por esta vaga

Remote and hybrid work options

Performance bonus

401(k) with company match

Competitive PTO

Health insurance

Telehealth services

Resumo da vaga

WPS Health Solutions is seeking an Appeals Nurse (RN) to review medical records and claims information for first-level appeal cases, determining medical necessity under Medicare guidelines. You will collaborate with Appeals Examiners to ensure redeterminations are medically reviewed and completed timely.

The role requires an active RN license (ASN/BSN), 1+ year clinical experience, strong communication and meticulous organizational skills, and the ability to work remotely from approved states.

Qualificações

• Associate's (ASN) or Bachelor's Degree in Nursing (BSN) required.
• Active RN license in good standing for state of practice.
• 1+ year of clinical experience in healthcare setting (hospital/bedside, case management, etc.).
• Excellent written and verbal communication skills.
• Strong attention to detail and organizational skills to manage multiple cases.
• Basic knowledge of medical/clinical review processes (Appeals/Utilization Review).
• Proficient with MS Office suite (Outlook, Teams, OneNote, Word, Excel).

Responsabilidades

• Review and assess first-level appeal cases for denied services with complete medical documentation.
• Conduct comprehensive medical record reviews to determine clinical necessity and provide recommendations based on guidelines and policy.
• Prepare and submit written appeal letters with rationales and supporting clinical evidence.
• Ensure timely follow-up on all appeals and proper resolution in line with policies and regulations.
• Maintain awareness of healthcare laws/regulations applicable to the appeals process and ensure compliance.
• Collaborate with Redetermination Representatives to ensure clinical decisions are addressed within CMS timelines.

Conhecimentos

Communication skills

Attention to detail

Organizational skills

Formação

ASN/BSN

Ferramentas

MS Outlook

Teams

OneNote

Word

Excel

Descrição da vaga

WPS Health Solutions is seeking an Appeals Nurse (RN) to review medical records and claims information for first-level appeal cases, determining medical necessity under Medicare guidelines. You will collaborate with Appeals Examiners to ensure redeterminations are medically reviewed and completed timely.

The role requires an active RN license (ASN/BSN), 1+ year clinical experience, strong communication and meticulous organizational skills, and the ability to work remotely from approved states.