Appeals Registered Nurse

WPS—A health solutions company•Fitchburg, WI

7d•$66,000 - $68,000•Remote

About The Position

The Appeals Registered Nurse examines medical records and claims information for first-level appeal cases to determine whether services provided were medically necessary and meet Medicare coverage guidelines, regulations, and policies. The RN collaborates with Appeals Examiners and Representatives to ensure cases requiring medical review receive appropriate redeterminations and are completed on time. The role reviews denied-service appeals, assesses clinical documentation and coding, determines medical necessity, prepares written appeal letters with supporting rationales and evidence, and follows cases through resolution in accordance with company policies and external requirements. The RN also provides direction to Redetermination Representatives and ensures clinical decisions meet CMS quality and timeliness standards. This position is open to remote work in specified approved states. Remote employees must have a wired Ethernet connection, high-speed cable or fiber internet, with minimum speeds of 10 Mbps downstream and 1 Mbps upstream. The position supports services under CMS contracts and is subject to applicable federal regulations, CMS requirements, and WPS policies, including data security, privacy, confidentiality, and program integrity requirements. Screening and background investigation, including fingerprinting, apply before access to systems or sensitive data is granted.

Requirements

Associate’s (ASN) or Bachelor’s degree in Nursing (BSN).
Active RN license applicable to the state of practice and in good standing.
At least one year of clinical experience in a healthcare setting, such as hospital/bedside, case management, or MDS/Skilled Nursing.
Excellent written and verbal communication skills, including the ability to communicate complex medical information clearly and concisely.
Strong attention to detail and organizational skills to manage multiple cases simultaneously.
Basic knowledge and understanding of medical or clinical review processes, such as Appeals or Utilization Review.
Computer skills and experience using multiple online systems, including MS Outlook, Teams, OneNote, Word, and Excel.
For remote work: wired Ethernet connection from router to computer; high-speed cable or fiber internet; at least 10 Mbps downstream and 1 Mbps upstream.

Nice To Haves

Experience working for a Medicare Administrative Contractor (MAC).
At least one year of experience in Medical Management (such as an MDS role), Medical Review, Utilization Management/Review, or Appeals.
Basic Medicare knowledge and/or experience.

Responsibilities

Review and assess first-level appeal cases for denied services, ensuring relevant medical documentation, coding, and clinical information are provided.
Conduct comprehensive medical record reviews to determine clinical necessity and recommend resolutions based on clinical guidelines, policy, and medical necessity.
Prepare and submit written appeal letters with comprehensive rationales and supporting clinical evidence.
Follow up on appeals to ensure timely and appropriate resolution under company policies and external regulations.
Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process and ensure compliance with regulatory and contractual requirements.
Work with and provide direction to Redetermination Representatives so cases requiring clinical decisions are completed within CMS quality and timeliness standards.

Benefits

Remote and hybrid work options available.
Performance bonus and/or merit increase opportunities.
401(k) with a 100% match for the first 3% of salary and a 50% match for the next 2%; immediately 100% vested.
Competitive paid time off.
Health insurance, dental insurance, and telehealth services starting on day one.
Professional and Leadership Development Programs.

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