Remote Appeals Nurse — Medicare Medical Necessity Expert

WPS Health Solutions; Omaha (NE); Remoto; USD 66.000 - 68.000; Tempo pieno

Vantaggi offerti da questo lavoro

Remote and hybrid work options

Performance bonus

401(k) match

Paid time off

Health insurance

Dental insurance

Telehealth services

Professional development

Descrizione del lavoro

WPS Health Solutions seeks an Appeals Nurse (RN) to review medical records for first-level appeal cases to determine medical necessity under Medicare guidelines. You will collaborate with Appeals Examiners to ensure timely redeterminations and proper documentation.

Requirements include ASN/BSN, active RN license, 1+ year clinical experience, and strong communication and organizational skills. Remote work is available for designated states, with competitive benefits and 401(k) matching.

Competenze

• ASN or BSN degree required.
• Active RN license in good standing.
• 1+ year of clinical healthcare experience.
• Excellent written and verbal communication.
• Strong attention to detail and organizational skills.
• Basic knowledge of medical review processes (Appeals/Utilization Review).
• Proficient in MS Office and online systems.

Mansioni

• Review first-level appeal cases and assess medical documentation for medical necessity.
• Conduct comprehensive medical record reviews to determine clinical necessity and provide recommendations.
• Prepare and submit written appeal letters with rationales and supporting evidence.
• Ensure timely follow-up on all appeals and adherence to policies and CMS requirements.
• Maintain awareness of healthcare laws, regulations, and CMS contract requirements.
• Coordinate with Redetermination Representatives to ensure responses meet CMS timelines.

Conoscenze

Communication skills

Attention to detail

Organizational skills

Medical terminology

Formazione

ASN or BSN

Strumenti

MS Outlook

Teams

OneNote

Word

Excel

Descrizione del lavoro

WPS Health Solutions seeks an Appeals Nurse (RN) to review medical records for first-level appeal cases to determine medical necessity under Medicare guidelines. You will collaborate with Appeals Examiners to ensure timely redeterminations and proper documentation.

Requirements include ASN/BSN, active RN license, 1+ year clinical experience, and strong communication and organizational skills. Remote work is available for designated states, with competitive benefits and 401(k) matching.