Remote Appeals RN: Medicare Medical Necessity Reviewer

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

Benefits offered by this job

Remote/hybrid options

Bonus potential

401(k) match

Health insurance

Paid time off

Professional development

Job summary

WPS—A health solutions company is seeking an Appeals Nurse to review medical records and claims information for first-level Medicare appeal cases, determining medical necessity and compliance with CMS guidelines. The RN collaborates with Appeals Examiners to ensure timely redeterminations.

This remote role is eligible in several states, including Florida, with a salary range of 66–68k annually. Benefits include health/dental, 401(k) matching, paid time off, and opportunities for professional

Qualifications

• Associate's (ASN) or Bachelor's Degree in Nursing (BSN).
• Active RN license in good standing for state of practice.
• 1+ year of clinical experience in healthcare settings.

Responsibilities

• Review first-level appeal cases to determine medical necessity and adherence to Medicare guidelines.
• Conduct medical record reviews and provide rationales for appeal decisions.
• Prepare written appeal letters with supporting clinical evidence.
• Ensure timely follow-up and resolution in line with policies and CMS requirements.
• Maintain knowledge of healthcare laws and CMS regulations relevant to appeals.
• Collaborate with Redetermination Representatives to meet CMS quality timelines.

Skills

Communication skills

Attention to detail

Organizational skills

Medical terminology

MS Outlook/Teams/OneNote/Word/Excel

Education

ASN or BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

WPS—A health solutions company is seeking an Appeals Nurse to review medical records and claims information for first-level Medicare appeal cases, determining medical necessity and compliance with CMS guidelines. The RN collaborates with Appeals Examiners to ensure timely redeterminations.

This remote role is eligible in several states, including Florida, with a salary range of 66–68k annually. Benefits include health/dental, 401(k) matching, paid time off, and opportunities for professional