Remote Appeals RN for Medicare Medical Necessity

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

Benefits offered by this job

Remote/hybrid options

Performance bonus

401(k) with match

Paid time off

Health, dental, telehealth from day 1

Professional development programs

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 per Medicare guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and compliant resolutions.

A valid RN license and clinical experience are required. The position offers remote work options across approved states with competitive benefits and opportunities for professional development.

Qualifications

• Active RN license in good standing
• 1+ year clinical healthcare experience
• Strong verbal and written communication
• Knowledge of medical record review processes
• Proficient with MS Office suite (Outlook/Teams/OneNote/Word/Excel)
• Ability to manage multiple cases with attention to detail

Responsibilities

• Review first-level appeal cases for medical necessity and documentation
• Conduct medical record reviews to support reviews with guidelines and policies
• Prepare and submit written appeal letters with rationales and evidence
• Ensure timely follow-up and compliance with CMS and contract requirements
• Stay updated on healthcare laws and CMS policies affecting appeals
• Coordinate with Redetermination Representatives to meet CMS timelines

Skills

Excellent communication

Attention to detail

Clinical experience

RN licensure

Medical review processes

MS Office proficiency

Education

ASN or BSN

Tools

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 per Medicare guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and compliant resolutions.

A valid RN license and clinical experience are required. The position offers remote work options across approved states with competitive benefits and opportunities for professional development.