Remote Appeals RN: Medicare Medical Review Expert

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

Benefits offered by this job

Remote and hybrid work options

Performance bonus

401(k) with match

Paid time off

Health insurance, dental, telehealth

Professional development

Job summary

WPS, a health solutions company, is seeking an Appeals Nurse (RN) to review medical records and Medicare denial cases for medical necessity. The role collaborates with Appeals Examiners to ensure timely redeterminations and adherence to CMS policies.

Qualified candidates hold an ASN or BSN and an active RN license, with 1+ year of clinical experience and strong communication skills. Remote work options available for approved states, including Texas.

Qualifications

• Active RN license in good standing
• Clinical experience of 1+ year in healthcare settings
• Excellent written and verbal communication skills
• Strong attention to detail and ability to manage multiple cases
• Basic knowledge of Appeals/Utilization Review processes
• Proficient in using MS Office and online systems

Responsibilities

• Review first-level appeal cases to determine medical necessity and coverage
• Conduct medical record reviews and provide recommendations based on guidelines
• Prepare and submit written appeal letters with rationales and evidence
• Ensure timely follow-up and resolution of appeals
• Maintain knowledge of healthcare laws, regulations and CMS requirements
• Collaborate with Redetermination Representatives to respond within CMS timelines

Skills

Communication

Attention to detail

Organizational skills

Clinical documentation

Education

ASN or BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

WPS, a health solutions company, is seeking an Appeals Nurse (RN) to review medical records and Medicare denial cases for medical necessity. The role collaborates with Appeals Examiners to ensure timely redeterminations and adherence to CMS policies.

Qualified candidates hold an ASN or BSN and an active RN license, with 1+ year of clinical experience and strong communication skills. Remote work options available for approved states, including Texas.