Remote Medicare Appeals RN — Clinical Review Expert

WPS Health Solutions; Green Bay (WI); Remote; USD 66,000 - 68,000; Full time

Benefits offered by this job

Remote and hybrid work options

Performance bonus

401(k) with 100% match for first 3%

Paid time off

Health and dental insurance

Telehealth services

Professional development programs

Job summary

WPS Health Solutions is seeking an Appeals Nurse (RN) to review medical records and claims for first-level Medicare appeal cases, assessing medical necessity and adherence to CMS guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and compliant processing.

The ideal candidate holds an ASN or BSN and an active RN license, with at least 1 year of clinical experience, strong communication, and solid understanding of medical review processes.

Qualifications

• Associate's (ASN) or Bachelor's Degree in Nursing (BSN).
• Active RN license in good standing.
• 1+ years of clinical experience in a healthcare setting.
• Excellent written and verbal communication skills.
• Strong attention to detail and organizational skills.
• Basic knowledge of medical/clinical review processes (i.e., Appeals/Utilization Review).
• Solid computer skills with MS Outlook, Teams, OneNote, Word, and Excel.

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 clinical necessity of services and make recommendations based on clinical guidelines and policies.
• Prepare and submit written appeal letters with comprehensive rationales and supporting clinical evidence.
• Ensure timely follow-up on all appeals and proper resolution in line with policies and regulations.
• Maintain awareness of healthcare laws and policies relevant to the appeals process.
• Coordinate with Redetermination Representatives to ensure timely responses to CMS quality and timelines standards.

Skills

RN license

Clinical experience

Communication skills

Documentation

Organizational skills

Tech literacy

Education

ASN/BSN

Tools

MS Outlook

Teams

OneNote

Word

Excel

Job description

WPS Health Solutions is seeking an Appeals Nurse (RN) to review medical records and claims for first-level Medicare appeal cases, assessing medical necessity and adherence to CMS guidelines. The role collaborates with Appeals Examiners to ensure timely redeterminations and compliant processing.

The ideal candidate holds an ASN or BSN and an active RN license, with at least 1 year of clinical experience, strong communication, and solid understanding of medical review processes.