Remote Medicare Appeals Nurse | Case Review Specialist

WPS—A health solutions company; Madison (WI); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote work

Bonus program

401(k) match

Paid time off

Health insurance

Telehealth services

Professional development

Job summary

WPS, a health solutions company, is seeking an Appeals Nurse to review medical records and claims for first-level Medicare appeal cases to determine medical necessity and adherence to CMS guidelines. The role supports timely redeterminations and collaborates with Appeals Examiners to ensure quality decisions.

The position requires an active RN license (state of practice) and 1+ year of clinical experience, with strong communication and healthcare regulatory knowledge.

Qualifications

• Active RN license in good standing.
• 1+ year of clinical healthcare experience.
• Strong written and verbal communication skills.
• Basic knowledge of medical review processes (Appeals/Utilization Review).
• Proficiency with MS Office and online systems.
• Familiarity with CMS/Medicare guidelines preferred.

Responsibilities

• Review and assess first-level appeal cases for denied services, ensuring all relevant medical documentation, coding, and clinical information are provided to support the appeal.
• Conduct comprehensive medical record reviews to determine the clinical necessity of services and make recommendations for resolution based on clinical guidelines, policy, and the medical necessity of care.
• Prepare and submit written appeal letters, including comprehensive rationales and supporting clinical evidence.
• Ensure timely follow-up on all appeals and ensure proper resolution is reached in accordance with company policies and external regulations.
• Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process, ensuring all actions comply with regulatory and contractual requirements.
• Work with and provide directions to Redetermination Representatives to ensure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards.

Skills

RN license

Clinical experience

Communication skills

Attention to detail

Medical review knowledge

MS Office proficiency

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 for first-level Medicare appeal cases to determine medical necessity and adherence to CMS guidelines. The role supports timely redeterminations and collaborates with Appeals Examiners to ensure quality decisions.

The position requires an active RN license (state of practice) and 1+ year of clinical experience, with strong communication and healthcare regulatory knowledge.