Remote Appeals Nurse: Medicare Medical Necessity Review

WPS Health Solutions; Indianapolis (IN); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote and hybrid work options

Performance bonus and merit increases

401(k) with employer match

Competitive paid time off

Health insurance starting Day 1

Professional and Leadership Develop.

Job summary

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

A strong RN license and clinical experience are required, with remote work options available in designated states. You will assess documentation, prepare comprehensive rationales, and stay updated on healthcare regulations.

Qualifications

• Associates or Bachelor's degree in nursing.
• Active RN license in good standing.
• 1+ year of clinical healthcare experience.
• Excellent written and verbal communication skills.

Responsibilities

• Review first-level appeal cases for medical necessity and CMS guidelines.
• Conduct medical record reviews to determine clinical necessity and provide rationales.
• Prepare and submit written appeal letters with supporting evidence.
• Ensure timely follow-up and proper resolution per policy and regulations.
• Maintain knowledge of healthcare laws and CMS requirements.
• Coordinate with Redetermination Representatives to respond within CMS timelines.

Skills

RN license

Clinical nursing experience

Strong communication

MS Office proficiency

Education

ASN or BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

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

A strong RN license and clinical experience are required, with remote work options available in designated states. You will assess documentation, prepare comprehensive rationales, and stay updated on healthcare regulations.