Remote Appeals RN: Medicare Case Review Specialist

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

Benefits offered by this job

Remote and hybrid work options

Performance bonus

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

Top-up PTO and paid time off

Health, dental, telehealth from day 1

Professional and Leadership Develop.

Job summary

WPS is seeking an Appeals Nurse to review medical records and Medicare claim information for first-level appeal cases. You will collaborate with Appeals Examiners to ensure timely redeterminations are medically reviewed and compliant with CMS guidelines.

Required RN license, ASN/BSN, and 1+ year clinical experience. Remote work is permitted in several states, including New Jersey, with full benefits and growth opportunities.

Qualifications

• Associate’s or Bachelor’s degree in nursing.
• Active RN license in good standing in state of practice.
• 1+ year of clinical experience in healthcare settings (hospital/bedside, case management, MDS, etc.).
• Excellent written and verbal communication skills.
• Strong attention to detail and organizational abilities.
• Basic knowledge of medical/clinical review processes (Appeals/Utilization Review).
• Proficiency with MS Office and online systems (Outlook, Teams, OneNote, Word, Excel).

Responsibilities

• Review first-level appeals to determine medical necessity and coverage.
• Conduct comprehensive medical record reviews and advise on resolution.
• Prepare and submit written appeal letters with rationales and evidence.
• Ensure timely follow-up and proper resolution per policies and regulations.
• Maintain awareness of healthcare laws, regulations, and CMS guidelines.
• Coordinate with Redetermination Representatives for timely responses.

Skills

Communication

Attention to detail

Clinical review knowledge

Education

ASN or BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

WPS is seeking an Appeals Nurse to review medical records and Medicare claim information for first-level appeal cases. You will collaborate with Appeals Examiners to ensure timely redeterminations are medically reviewed and compliant with CMS guidelines.

Required RN license, ASN/BSN, and 1+ year clinical experience. Remote work is permitted in several states, including New Jersey, with full benefits and growth opportunities.