Appeals Nurse
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Registered Nurse reviewing medical necessity and Medicare appeal cases for WPS, a nonprofit health insurer and federal government contractor. Preparing clinical rationales and guiding timely CMS-compliant redeterminations.
Responsibilities:
- Review and assess first-level appeal cases for denied services
- Ensure relevant medical documentation, coding, and clinical information support each appeal
- Conduct comprehensive medical record reviews to determine clinical necessity of services
- Make recommendations for resolution based on clinical guidelines, policy, and medical necessity of care
- Prepare and submit written appeal letters with comprehensive rationales and supporting clinical evidence
- Follow up on appeals and ensure proper resolution in accordance with company policies and external regulations
- Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process
- Work with and provide direction to Redetermination Representatives
- Ensure clinically determined redeterminations are responded to within CMS quality and timeline standards
- Collaborate with Appeals Examiners/Reps to complete medical reviews and redeterminations timely
Requirements:
- Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN)
- Active RN license, applicable to state of practice in good standing
- One (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
- Experience working for a Medicare Administrative Contractor (MAC) preferred
- One (1) or more years of experience working in Medical Management, Medical Review, Utilization Management/Review, or Appeals preferred
- Basic Medicare knowledge and/or experience preferred
- Wired (ethernet cable) internet connection from router to computer
- High speed cable or fiber internet connection
- Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection
- Subject to applicable federal regulations, CMS contract requirements, and WPS internal policies, including data security, privacy, confidentiality, and program integrity requirements
- Subject to screening and background investigation including fingerprinting prior to access to information systems and/or sensitive data
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
- Professional and Leadership Development Programs
Similar Jobs
LPN
Preventive Care LPN delivering in-home screenings, blood pressure checks, and specimen collection. Supporting CenterWell’s personalized home healthcare through accurate EMR documentation.
Nurse Specialist II
Nurse Specialist II reviewing Medicare and Medicaid records and claims for Qlarant, a healthcare-programs nonprofit. Identifying overpayments, fraud, waste, and abuse through audits and investigations.
Nurse
Remote Nurse managing patient messages, routine clinical inquiries, and follow-ups for LumiMeds’ U.S. telehealth weight-management platform. Escalating complex concerns and maintaining HIPAA-compliant documentation.
Utilization Management Nurse
Utilization Management Nurse reviewing authorizations, hospital stays, and transitions for Curana Health’s value-based senior healthcare programs. Supporting quality outcomes and cost-effective care remotely.
Oncology Administrative Nurse
Remote oncology administrative nurse processing prescriptions and refill requests for Adjuvant Behavioral Health. Supporting patient care plans and medication oversight for oncology patients, families, and caregivers.
Care Coordinator – LPN/LVN
Care Coordinator/LPN supporting patients, families, and providers in Empassion’s palliative care program. Coordinating appointments, clinical documentation, triage, and follow-up remotely.
Case Manager, Registered Nurse
Remote RN case manager at CVS Health, coordinating personalized care and discharge planning for members nationwide. Advocating for access, quality outcomes, and cost-effective healthcare.
Research Nurse – Per Diem Independent Contractor
Part-time research nurse conducting mobile clinical-trial visits for Illingworth Research Group. Administering trial medication, collecting samples, and maintaining GCP-compliant study data.
Home Infusion Registered Nurse, PRN
PRN Home Infusion RN administering specialty medications and monitoring patients in their homes. Supporting CSI Pharmacy’s specialty care services across the Las Vegas area.
Registered Nurse
Registered Nurse supporting patients through Mosh & Moshy’s Australian digital health platform. Delivering telehealth assessment, triage, education and care coordination remotely.
Veterinary Nurse
Veterinary Nurse providing surgical, anaesthetic, medical, and hospital care at Greencross Vets Mount Gravatt. Supporting veterinarians, patients, clients, and daily clinic operations.
Behavioral Health Licensed Practical Nurse, LPN
Remote behavioral health LPN coordinating admissions, clinical screening, and patient transfers. Supporting Lifepoint Health facilities through triage, compliance, and patient-flow management.
Utilization Review Nurse
Utilization Review Nurse conducting remote workers’ compensation utilization reviews. Evaluating medical necessity, coordinating discharge planning, and referring cases for case management.
Registered Nurse, CA RN License Required
Remote Registered Nurse delivering virtual geriatric primary care for Pine Park Health. Coordinating assessments, triage, care plans, and chronic-care support for senior living residents.
Case Manager, Registered Nurse
Remote RN Case Manager coordinating CVS Health members’ clinical care, benefits, and wellness. Assessing needs and managing care through telephonic and face-to-face member engagement.
Case Manager, Registered Nurse
Remote RN Case Manager coordinating telephonic and face-to-face care for CVS Health members. Assessing medical needs, benefits, risks, and wellness outcomes.
Case Manager, Registered Nurse
Remote RN Case Manager assessing members and coordinating care plans for CVS Health. Supporting wellness through clinical judgment, benefits review, and case management.
Clinical Review Nurse – Concurrent Review
Clinical Review Nurse conducting concurrent utilization reviews for Centene’s Medicaid and Ambetter members. Evaluating medical necessity, care levels, and discharge planning remotely.
Utilization Review Nurse
Utilization Review Nurse reviewing emergency admissions and continued stays using InterQual or MCG criteria. Supporting authorization decisions and appropriate healthcare resource utilization at Netsmart.
Registered Nurse, Case Manager, Care Coordination
RN case manager coordinating patient-centered care for Geisinger Health Plan. Assessing needs, developing care plans, and optimizing clinical, quality, and fiscal outcomes.