Remote Appeals Registered Nurse - Medicare Medical Review

WPS—A health solutions company; Ohio; Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote work options

Performance bonus

401(k) with match

Paid time off

Health insurance

Dental insurance

Telehealth services

Professional development

Job summary

WPS Health Solutions is seeking an Appeals Nurse (RN) to review medical records and claims for first-level appeal cases, determining medical necessity and Medicare coverage compliance. The RN collaborates with Appeals Examiners to ensure redeterminations are reviewed and completed in a timely manner.

This position supports remote work in approved states, including Ohio. Ideal candidates will have an ASN/BSN, active RN license, 1+ year clinical experience, and strong communication skills to

Qualifications

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

Responsibilities

• Review and assess first-level appeal cases for denied services with complete medical documentation and clinical information.
• Conduct medical record reviews to determine clinical necessity and provide recommendations based on guidelines and policies.
• Prepare and submit written appeal letters with comprehensive rationales and supporting evidence.
• Ensure timely follow-up on all appeals and proper resolution per company policies and external regulations.
• Maintain awareness of healthcare laws, regulations, and CMS requirements relevant to appeals.
• Coordinate with Redetermination Representatives to ensure responses within CMS quality and timelines.

Skills

RN license

Clinical experience

Communication skills

Attention to detail

Medical review knowledge

MS Office proficiency

Education

ASN or BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

WPS Health Solutions is seeking an Appeals Nurse (RN) to review medical records and claims for first-level appeal cases, determining medical necessity and Medicare coverage compliance. The RN collaborates with Appeals Examiners to ensure redeterminations are reviewed and completed in a timely manner.

This position supports remote work in approved states, including Ohio. Ideal candidates will have an ASN/BSN, active RN license, 1+ year clinical experience, and strong communication skills to