WPS—A health solutions company
Join to apply for the
Appeals Nurse
role at
WPS—A health solutions company .
The Appeals Nurse examines medical records and claim information for first‑level appeal cases to determine whether services provided were medically necessary and met 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 in a timely manner.
Key Responsibilities
Review and analyze medical records and claim data for appeal readiness.
Determine medical necessity and Medicare coverage compliance.
Collaborate with Appeals Examiners and Reps to complete timely redeterminations.
Maintain documentation and quality metrics for all processed cases.
Required Qualifications
Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
Active RN license in good standing, applicable to state of practice.
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.
Strong attention to detail and organizational skills to manage multiple cases simultaneously.
Basic knowledge of medical review processes (Appeals/Utilization Review).
Solid computer skills with experience using MS Outlook, Teams, OneNote, Word, and Excel.
Preferred Qualifications
Experience working for a Medicare Administrative Contractor (MAC).
Experience in Medical Management, 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 (can be checked at https://speedtest.net).
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, dental, and telehealth services start DAY 1.
Employee Resource Groups.
Professional and Leadership Development Programs.
Additional benefits details .
Salary Range: $66,000 – $68,000.
Work Location: Remote work is open to the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin.
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, and processes claims and provides customer support for beneficiaries of the Medicare program.
We manage benefits for millions of active‑day and retired military personnel across the U.S. and abroad.
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
Appeals Nurse
role at
WPS—A health solutions company .
The Appeals Nurse examines medical records and claim information for first‑level appeal cases to determine whether services provided were medically necessary and met 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 in a timely manner.
Key Responsibilities
Review and analyze medical records and claim data for appeal readiness.
Determine medical necessity and Medicare coverage compliance.
Collaborate with Appeals Examiners and Reps to complete timely redeterminations.
Maintain documentation and quality metrics for all processed cases.
Required Qualifications
Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
Active RN license in good standing, applicable to state of practice.
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.
Strong attention to detail and organizational skills to manage multiple cases simultaneously.
Basic knowledge of medical review processes (Appeals/Utilization Review).
Solid computer skills with experience using MS Outlook, Teams, OneNote, Word, and Excel.
Preferred Qualifications
Experience working for a Medicare Administrative Contractor (MAC).
Experience in Medical Management, 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 (can be checked at https://speedtest.net).
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, dental, and telehealth services start DAY 1.
Employee Resource Groups.
Professional and Leadership Development Programs.
Additional benefits details .
Salary Range: $66,000 – $68,000.
Work Location: Remote work is open to the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin.
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, and processes claims and provides customer support for beneficiaries of the Medicare program.
We manage benefits for millions of active‑day and retired military personnel across the U.S. and abroad.
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