Remote Appeals Nurse - Medicare Medical Review

WPS Health Solutions; Charlotte (NC); À distance; USD 66 000 - 68 000; Plein temps

Avantages offerts par ce poste

Remote work options

Performance bonus

401(k) with 100% match for first 3% +

50% match for next 2%

Competitive paid time off

Health insurance starting DAY 1

Professional development programs

Résumé du poste

WPS Health Solutions is seeking an Appeals Nurse (RN) to analyze medical records for first-level appeals and determine medical necessity under Medicare guidelines. The role collaborates with Appeals Examiners to support timely redeterminations.

Qualified candidates hold an ASN or BSN, active RN license, and 1+ year of clinical experience, with strong communication and computer skills. Remote work is available in listed states, including North Carolina.

Qualifications

• Associate's or Bachelor's Degree in Nursing (ASN/BSN).
• Active RN license in good standing for state of practice.
• 1+ year of clinical healthcare experience.
• Excellent written and verbal communication skills.
• Strong attention to detail and organizational ability.
• Basic knowledge of Appeals/Utilization Review processes.
• Proficient with MS Office apps (Outlook/Teams/OneNote/Word/Excel).

Responsabilités

• Review first-level appeal cases to determine medical necessity.
• Conduct medical record reviews and assess clinical guidelines.
• Prepare and submit written appeal letters with rationale.
• Ensure timely follow-up and resolution per policy.
• Stay current with healthcare laws and CMS requirements.
• Coordinate with Redetermination Representatives for timely responses.

Connaissances

Medical record review

Clinical decision making

Communication skills

Attention to detail

Organizational skills

MS Outlook

Teams

OneNote

Word

Excel

Formation

ASN or BSN in Nursing

Outils

MS Outlook

Teams

OneNote

Word

Excel

Description du poste

WPS Health Solutions is seeking an Appeals Nurse (RN) to analyze medical records for first-level appeals and determine medical necessity under Medicare guidelines. The role collaborates with Appeals Examiners to support timely redeterminations.

Qualified candidates hold an ASN or BSN, active RN license, and 1+ year of clinical experience, with strong communication and computer skills. Remote work is available in listed states, including North Carolina.