Remote Appeals Nurse - Medicare Medical Necessity Expert

WPS Health Solutions; Marion (IL); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote and hybrid work options

Performance bonus

401(k) with 100% match for 3%

Competitive PTO

Health insurance starting DAY 1

Professional development program

Know Your Rights information

Job summary

WPS Health Solutions is hiring an Appeals Nurse to review medical records and determine medical necessity for first-level appeals. The role collaborates with Appeals Examiners to ensure timely redeterminations in line with Medicare guidelines.

The ideal candidate holds ASN/BSN, an active RN license, and 1+ year of clinical experience, with strong communication and organizational skills. Remote work options are available with state-specific approvals.

Qualifications

• Associate's or Bachelor's Degree in Nursing
• Active RN license in state of practice
• 1+ year of clinical healthcare experience
• Excellent written and verbal communication skills
• Strong attention to detail and organizational skills
• Basic knowledge of medical/clinical review processes
• Proficient with MS Office and online systems

Responsibilities

• Review first-level appeal cases for medical necessity and CMS guidelines.
• Perform comprehensive medical record reviews to assess clinical necessity and provide recommendations.
• Prepare and submit written appeal letters with rationales and supporting evidence.
• Ensure timely follow-up and resolution of all appeals.
• Maintain awareness of healthcare laws and CMS requirements.
• Coordinate with Redetermination Representatives to meet CMS timelines.

Skills

Written and verbal communication

Attention to detail

Organization

Multitasking

Team collaboration

Education

ASN or BSN in Nursing

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

WPS Health Solutions is hiring an Appeals Nurse to review medical records and determine medical necessity for first-level appeals. The role collaborates with Appeals Examiners to ensure timely redeterminations in line with Medicare guidelines.

The ideal candidate holds ASN/BSN, an active RN license, and 1+ year of clinical experience, with strong communication and organizational skills. Remote work options are available with state-specific approvals.