WPS—A health solutions company
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Appeals Nurse
role at
WPS—A health solutions company
Overview 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 collaborates with the Appeals Examiners and Reps to ensure redeterminations are medically reviewed as needed and completed timely.
Salary Range $66,000 - $68,000
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
Review medical records and claims information for first-level appeal cases to determine medical necessity and adherence to Medicare coverage guidelines.
Collaborate with Appeals Examiners and Reps to ensure timely and accurate redeterminations.
Maintain compliance with Medicare regulations and internal policies.
What you will gain from this role
Collaborating with a team of clinicians and non-clinicians.
Experience with systems such as the Medicare Appeal System (MAS) and Hyland OnBase.
Experience serving military personnel, veterans, and Medicare beneficiaries.
Working in a continuous performance feedback environment.
Minimum Qualifications
Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
Active RN license in good standing in the state of practice.
1+ years of clinical experience in a healthcare setting (hospital/bedside, case management, MDS/Skilled Nursing, etc.).
Excellent written and verbal communication skills; ability to convey complex medical information clearly.
Strong attention to detail and organizational skills to manage multiple cases.
Basic knowledge of medical/clinical review processes (e.g., Appeals/Utilization Review).
Solid computer skills with MS Outlook, Teams, OneNote, Word, and Excel.
Preferred Qualifications
Experience with a Medicare Administrative Contractor (MAC).
1+ years in Medical Management, Medical Review, Utilization Management/Review, or Appeals.
Basic Medicare knowledge or experience.
Remote Work Requirements
Wired internet connection from your router to your computer (Ethernet).
High-speed cable or fiber internet.
Minimum 10 Mbps downstream and 1 Mbps upstream.
Benefits
Remote and hybrid work options available.
Performance bonus and/or merit increases.
401(k) with employer match; fully vested.
Competitive paid time off and health benefits starting Day 1.
Employee Resource Groups and Professional/Leadership Development Programs.
About Us WPS Health Solutions is a not-for-profit health insurer and federal government contractor headquartered in Wisconsin. We serve individuals, families, seniors, and groups, processing claims and supporting beneficiaries of the Medicare program and military personnel. Proud to be military and veteran ready.
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Appeals Nurse
role at
WPS—A health solutions company
Overview 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 collaborates with the Appeals Examiners and Reps to ensure redeterminations are medically reviewed as needed and completed timely.
Salary Range $66,000 - $68,000
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
Review medical records and claims information for first-level appeal cases to determine medical necessity and adherence to Medicare coverage guidelines.
Collaborate with Appeals Examiners and Reps to ensure timely and accurate redeterminations.
Maintain compliance with Medicare regulations and internal policies.
What you will gain from this role
Collaborating with a team of clinicians and non-clinicians.
Experience with systems such as the Medicare Appeal System (MAS) and Hyland OnBase.
Experience serving military personnel, veterans, and Medicare beneficiaries.
Working in a continuous performance feedback environment.
Minimum Qualifications
Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
Active RN license in good standing in the state of practice.
1+ years of clinical experience in a healthcare setting (hospital/bedside, case management, MDS/Skilled Nursing, etc.).
Excellent written and verbal communication skills; ability to convey complex medical information clearly.
Strong attention to detail and organizational skills to manage multiple cases.
Basic knowledge of medical/clinical review processes (e.g., Appeals/Utilization Review).
Solid computer skills with MS Outlook, Teams, OneNote, Word, and Excel.
Preferred Qualifications
Experience with a Medicare Administrative Contractor (MAC).
1+ years in Medical Management, Medical Review, Utilization Management/Review, or Appeals.
Basic Medicare knowledge or experience.
Remote Work Requirements
Wired internet connection from your router to your computer (Ethernet).
High-speed cable or fiber internet.
Minimum 10 Mbps downstream and 1 Mbps upstream.
Benefits
Remote and hybrid work options available.
Performance bonus and/or merit increases.
401(k) with employer match; fully vested.
Competitive paid time off and health benefits starting Day 1.
Employee Resource Groups and Professional/Leadership Development Programs.
About Us WPS Health Solutions is a not-for-profit health insurer and federal government contractor headquartered in Wisconsin. We serve individuals, families, seniors, and groups, processing claims and supporting beneficiaries of the Medicare program and military personnel. Proud to be military and veteran ready.
#J-18808-Ljbffr