Remote Appeals Registered Nurse - Medicare Case Review

WPS Health Solutions; Des Moines (IA); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote work options

Performance bonus opportunity

401(k) match

Job summary

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

Required ASN/BSN, active RN license, and 1+ year clinical experience, with strong communication and regulatory knowledge. Remote work is available in approved states, with competitive benefits.

Qualifications

• ASN or BSN required.
• Active RN license in good standing in state of practice.
• 1+ years of clinical healthcare experience.
• Excellent written and verbal communication skills.
• Strong attention to detail and organizational skills.
• Basic knowledge of medical review processes (Appeals/Utilization Review).
• Experience with MS Outlook, Teams, OneNote, Word and Excel.

Responsibilities

• 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 clinical necessity and make recommendations for resolution based on guidelines and policy.
• Prepare and submit written appeal letters with comprehensive rationales and supporting clinical evidence.
• Ensure timely follow-up on all appeals and proper resolution per company policies and external regulations.
• Maintain awareness of healthcare laws and policies relevant to the appeals process; ensure regulatory compliance.
• Collaborate with Redetermination Representatives to ensure timely clinical decisions within CMS timelines.

Skills

RN license

Clinical experience

Communication

Attention to detail

Regulatory knowledge

Education

ASN/BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

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

Required ASN/BSN, active RN license, and 1+ year clinical experience, with strong communication and regulatory knowledge. Remote work is available in approved states, with competitive benefits.