Remote Appeals Nurse: Medicare Medical Necessity Expert

WPS Health Solutions; Newark (NJ); Remote; USD 66.000 - 68.000; Vollzeit

Benefits dieser Stelle

Remote work options

Performance bonus

401(k) with match

Zusammenfassung

WPS Health Solutions is seeking an Appeals Nurse (RN) to review first-level appeal cases for medical necessity and CMS compliance. You will collaborate with Appeals Examiners to ensure timely redeterminations and coordinate medical record reviews.

The role requires an active RN license (state of practice) and 1+ year clinical experience, with strong communication and organization skills. The position supports remote work allowed in approved states, with salary in the 66-68k range and a focus on

Qualifikationen

• ASN or BSN required.
• Active RN license in good standing.
• 1+ year of clinical experience in healthcare.
• Strong written and verbal communication.
• Excellent attention to detail and organization.
• Basic knowledge of Appeals/Utilization Review.
• MS Office proficiency.

Aufgaben

• Review and assess first-level appeal cases for denied services, ensuring all relevant medical documentation, coding, and clinical information are provided to support the appeal.
• Conduct comprehensive medical record reviews to determine the clinical necessity of services and make recommendations for resolution based on clinical guidelines, policy, and the medical necessity of care.
• Prepare and submit written appeal letters, including comprehensive rationales and supporting clinical evidence.
• Ensure timely follow-up on all appeals and ensure proper resolution is reached in accordance with company policies and external regulations.
• Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process, ensuring all actions comply with regulatory and contractual requirements.
• Work with and provide directions to Redetermination Representatives to ensure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards.

Kenntnisse

RN license

Clinical experience

Medical records review

Communication skills

Organizational skills

MS Office proficiency

Ausbildung

ASN or BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Jobbeschreibung

WPS Health Solutions is seeking an Appeals Nurse (RN) to review first-level appeal cases for medical necessity and CMS compliance. You will collaborate with Appeals Examiners to ensure timely redeterminations and coordinate medical record reviews.

The role requires an active RN license (state of practice) and 1+ year clinical experience, with strong communication and organization skills. The position supports remote work allowed in approved states, with salary in the 66-68k range and a focus on