Remote Medicare Appeals Nurse

WPS Health Solutions; Houston (TX); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote work options

Hybrid work options

Performance bonus

401(k) with match

Job summary

WPS Health Solutions is seeking an Appeals Nurse to examine medical records and claims information for first-level appeal cases to determine whether services were medically necessary and meet Medicare guidelines. The role collaborates with Appeals Examiners to ensure redeterminations are reviewed as needed and completed timely.

This position supports remote work in multiple states, with a base salary of 66–68k, and requires RN licensure, ASN/BSN, and clinical experience.

Qualifications

• Associate's or Bachelor's degree in Nursing (ASN/BSN).
• Active RN license in good standing.
• One year of clinical healthcare experience.
• Excellent written and verbal communication.
• Attention to detail and organizational skills.
• Basic knowledge of medical/clinical review processes.
• Proficient with MS Office suite.

Responsibilities

• Review first-level appeal cases for medical necessity and CMS guidelines.
• Conduct comprehensive medical record reviews.
• Prepare and submit written appeal letters with rationale and evidence.
• Ensure timely follow-up and proper resolution per policies/regulations.
• Stay updated on healthcare laws and CMS policies.
• Coordinate with Redetermination Representatives for CMS timelines.

Skills

RN license in good standing

Clinical experience in healthcare

Strong communication skills

MS Outlook/Teams/OneNote/Word/Excel

Education

ASN or BSN

Tools

MS Outlook

Microsoft Teams

OneNote

Word

Excel

Job description

WPS Health Solutions is seeking an Appeals Nurse to examine medical records and claims information for first-level appeal cases to determine whether services were medically necessary and meet Medicare guidelines. The role collaborates with Appeals Examiners to ensure redeterminations are reviewed as needed and completed timely.

This position supports remote work in multiple states, with a base salary of 66–68k, and requires RN licensure, ASN/BSN, and clinical experience.