Remote Medicare Appeals Nurse | Case Review Pro

WPS—A health solutions company; Indiana; À distance; USD 66 000 - 68 000; Plein temps

Avantages offerts par ce poste

Remote/work options available

Bonus opportunities

401(k) match

Paid time off

Health insurance from Day 1

Résumé du poste

WPS—A health solutions company is seeking an Appeals Nurse to review medical records and claims for first-level appeal cases to determine medical necessity and adherence to Medicare coverage guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and accurate documentation.

Ideal candidates hold an ASN/BSN with an active RN license and 1+ year of clinical experience, strong communication, and proficiency in MS Office.

Qualifications

• ASN or BSN nursing degree; active RN license in good standing.
• 1+ year of clinical healthcare experience.
• Strong written and verbal communication; ability to convey complex medical information.
• Proficient with MS Office and online systems.

Responsabilités

• Review first-level appeal cases with medical documentation to support appeals.
• Perform medical record reviews to determine medical necessity and provide recommendations.
• Prepare and submit written appeal letters with rationales and clinical evidence.
• Ensure timely follow-up and resolution per policies and regulations.
• Maintain awareness of healthcare laws and CMS requirements affecting appeals.
• Coordinate with Redetermination Representatives to meet CMS timelines.

Connaissances

RN license

Clinical experience

Communication skills

Detail oriented

MS Outlook/Teams/OneNote/Word/Excel

Formation

ASN or BSN

Outils

MS Outlook

Teams

OneNote

Word

Excel

Description du poste

WPS—A health solutions company is seeking an Appeals Nurse to review medical records and claims for first-level appeal cases to determine medical necessity and adherence to Medicare coverage guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and accurate documentation.

Ideal candidates hold an ASN/BSN with an active RN license and 1+ year of clinical experience, strong communication, and proficiency in MS Office.