REMOTE RN - Health Insurance

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/Reps to ensure redeterminations are medically reviewed as needed and completed timely.

We are open to remote work in the following approved states: Review and assess first-level appeal cases for denied services, ensuring all relevant medical documentation, coding, and clinical information are provided to support the appeal.

Conduct comprehensive medical record reviews to determine the clinical necessity of services and make recommendations for resolution based on clinical guidelines, policy, and the medical necessity of care.

Ensure timely follow-up on all appeals and ensure proper resolution is reached in accordance with company policies and external regulations.

Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process, ensuring all actions comply with regulatory and contractual requirements.

Work with and provide directions to Redetermination Representatives to ensure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards.

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.

Basic knowledge and understanding of medical/clinical review processes (i.e., 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 (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals preferred.

Remote Work Requirements

Wired (ethernet cable) internet connection from your router to your computer.

High speed cable or fiber

Please review Remote Worker FAQs for additional information.

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)

Health insurance, dental insurance, and telehealth services start DAY 1

WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, 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.WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: Medicare (GHA)
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 including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

J-18808-Ljbffr WPS Health Solutions