Remote Appeals RN for Medicare Medical Necessity

WPS Health Solutions; Charleston (SC); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote options

Bonus opportunities

401(k) with match

Paid time off

Health insurance

Job summary

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

The role supports remote work in multiple states and offers a base salary of 66–68k with performance-based opportunities. Ideal candidates have an active RN license and 1+ year of clinical experience.

Qualifications

• Associate's or Bachelor's degree in Nursing.
• Active RN license in good standing.
• 1+ years of clinical experience in healthcare (hospital/bedside, case management, MDS/Skilled Nursing, etc.).
• 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 experience using MS Outlook, Teams, OneNote, Word, and Excel.

Responsibilities

• Review and assess first-level appeal cases for denied services, ensuring all medical documentation and clinical information are provided to support the appeal.
• Conduct comprehensive medical record reviews to determine clinical necessity and make recommendations based on guidelines, policy, and medical necessity.
• 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.
• Remain aware of healthcare laws and CMS requirements affecting the appeals process.
• Coordinate with Redetermination Representatives to ensure timely responses to CMS quality and timelines standards.

Skills

Communication skills

Attention to detail

MS Office/Outlook

Medical terminology

Medicare knowledge

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 to determine medical necessity and compliance with Medicare guidelines. You will collaborate with Appeals Examiners to ensure timely redeterminations and quality outcomes.

The role supports remote work in multiple states and offers a base salary of 66–68k with performance-based opportunities. Ideal candidates have an active RN license and 1+ year of clinical experience.