Appeals Nurse (RN) - Remote

WPS Health • Denver, CO

411d • $66,000 - $68,000 • Remote

About The Position

The Appeals Nurse at WPS Health Solutions is responsible for examining medical records and claims information for first-level appeal cases to determine the medical necessity of services provided, ensuring compliance with Medicare coverage guidelines. This role involves utilizing clinical knowledge to conduct medical reviews, providing clear written explanations for claims decisions, and collaborating with Redetermination Representatives to meet CMS quality standards. The position emphasizes critical thinking, organization, and technical writing skills, while offering a supportive environment focused on continuous quality improvement.

Requirements

• Associate's (ASN) or Bachelor's Degree in Nursing (BSN).
• Active RN license in good standing.

Nice To Haves

• 1 or more years of experience with another Medicare Administrative Contractor (MAC).
• 1 or more years in Medical Management, Medical Review, Utilization Management/Review, or Appeals.
• Strong technical writing skills.
• 4 or more years of experience in clinical nursing.
• Experience working with Medicare Part A and Part B.
• Experience in a remote work environment.

Responsibilities

• Examine medical records and claims information for first-level appeal cases.
• Utilize clinical knowledge to conduct medical reviews of claim documentation.
• Provide clear written explanations for claims that cannot be paid due to first-level redetermination.
• Work with Redetermination Representatives to ensure timely responses to clinical decisions.
• Analyze appeals to identify high-volume problem issues and communicate findings to management.
• Participate in workgroups for Continuous Quality Improvement (CQI) to promote consistent medical review.

Benefits

• Remote and hybrid work options available.
• Performance bonus and/or merit increase opportunities.
• 401(k) with dollar-per-dollar match up to 6% of salary (100% vested immediately).

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree