Remote Appeals RN - Medicare Medical Necessity

WPS Health Solutions; Kansas City (MO); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote and hybrid work options

Performance bonus and merit increases

401(k) with full company match for 3%

Job summary

WPS Health Solutions is seeking an Appeals Nurse (RN) to examine medical records and claims for first-level appeal cases to determine medical necessity and adherence to Medicare guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and compliant review.

You will review documentation, prepare written letters with rationales, and monitor follow-ups while staying current with healthcare laws and CMS requirements.

Qualifications

• Associate's (ASN) or Bachelor's Degree in Nursing (BSN).
• Active RN license in good standing.
• 1+ years of clinical healthcare experience.
• Excellent written and verbal communication skills.
• Strong attention to detail and organization.
• Basic knowledge of medical/clinical review processes (Appeals/Utilization Review).
• MS Outlook, Teams, OneNote, Word, and Excel proficiency.

Responsibilities

• Review and assess first-level appeal cases with medical documentation to support the appeal.
• Conduct medical record reviews to determine clinical necessity and make recommendations.
• Prepare and submit written appeal letters with comprehensive rationales and supporting evidence.
• Ensure timely follow-up on all appeals and proper resolution per policies and regulations.
• Stay updated on healthcare laws, regulations, and CMS requirements.
• Coordinate with Redetermination Representatives to ensure timely CMS-compliant responses.

Skills

RN license

Clinical nursing experience

Communication skills

Attention to detail

Medical review knowledge

MS Office proficiency

Education

ASN/BSN in Nursing

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

WPS Health Solutions is seeking an Appeals Nurse (RN) to examine medical records and claims for first-level appeal cases to determine medical necessity and adherence to Medicare guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and compliant review.

You will review documentation, prepare written letters with rationales, and monitor follow-ups while staying current with healthcare laws and CMS requirements.