WPS—A health solutions company
Overview
Join to apply for the
Appeals Nurse
role at
WPS—A health solutions company . The Appeals 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 in accordance with Medicare regulations and policies. The Appeals RN works in collaboration with the Appeals Examiners and Reps to ensure redeterminations are medically reviewed as needed and completed timely. Salary
$66,000 - $68,000 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Work Location
We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin Responsibilities
Examine medical records and claims information for first-level appeal cases to determine medical necessity and alignment with Medicare coverage guidelines. Collaborate with Appeals Examiners and Representatives to ensure timely and medically reviewed redeterminations. Utilize Medicare regulations and policies to support decision making. Required and Preferred Qualifications
Minimum Qualifications
Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN). Active RN license, applicable to state of practice in good standing. 1 or more years of clinical experience in a healthcare setting (hospital/bedside, case management, MDS/Skilled Nursing, etc.). Excellent written and verbal communication skills, with 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/clinical review processes (i.e., Appeals/Utilization Review). Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel. Preferred Qualifications
Experience working for a Medicare Administrative Contractor (MAC). 1 or more years of experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals. Basic Medicare knowledge and/or experience. Remote Work Requirements
Wired (ethernet cable) internet connection from your router to your computer High speed cable or fiber internet Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection Please review Remote Worker FAQs for additional information 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 your salary and a 50% match for the next 2% of your salary (100% vested immediately) Competitive paid time off Health insurance, dental insurance, and telehealth services start DAY 1 Employee Resource Groups Professional and Leadership Development Programs Review additional benefits: https://www.wpshealthsolutions.com/careers/fulltime_benefits.shtml Who We Are
WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready. Culture Drives Our Success
WPS’ Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities. This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services.
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Join to apply for the
Appeals Nurse
role at
WPS—A health solutions company . The Appeals 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 in accordance with Medicare regulations and policies. The Appeals RN works in collaboration with the Appeals Examiners and Reps to ensure redeterminations are medically reviewed as needed and completed timely. Salary
$66,000 - $68,000 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Work Location
We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin Responsibilities
Examine medical records and claims information for first-level appeal cases to determine medical necessity and alignment with Medicare coverage guidelines. Collaborate with Appeals Examiners and Representatives to ensure timely and medically reviewed redeterminations. Utilize Medicare regulations and policies to support decision making. Required and Preferred Qualifications
Minimum Qualifications
Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN). Active RN license, applicable to state of practice in good standing. 1 or more years of clinical experience in a healthcare setting (hospital/bedside, case management, MDS/Skilled Nursing, etc.). Excellent written and verbal communication skills, with 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/clinical review processes (i.e., Appeals/Utilization Review). Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel. Preferred Qualifications
Experience working for a Medicare Administrative Contractor (MAC). 1 or more years of experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals. Basic Medicare knowledge and/or experience. Remote Work Requirements
Wired (ethernet cable) internet connection from your router to your computer High speed cable or fiber internet Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection Please review Remote Worker FAQs for additional information 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 your salary and a 50% match for the next 2% of your salary (100% vested immediately) Competitive paid time off Health insurance, dental insurance, and telehealth services start DAY 1 Employee Resource Groups Professional and Leadership Development Programs Review additional benefits: https://www.wpshealthsolutions.com/careers/fulltime_benefits.shtml Who We Are
WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready. Culture Drives Our Success
WPS’ Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities. This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services.
#J-18808-Ljbffr