Appeals Nurse

Job not on LinkedIn

🔥 15 hours ago

⛰️ Colorado, Florida, +13 more states – Remote

⛰️ Colorado – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌾 Nebraska – Remote 🏖️ New Jersey – Remote 🌲 North Carolina – Remote 🏈 Ohio – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🌴 South Carolina – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote 🧀 Wisconsin – Remote

💵 $66k - $68k / year

⏰ Full Time

🟢 Junior

👻 Ghost score 0%

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WPS Health Solutions

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🛡️ Insurance

🏥 Healthcare

🏛️ Government

💰 Venture Round on 2025-10

Insurance • Healthcare • Government

WPS Health Solutions is a not-for-profit health solutions company based in Madison, Wisconsin, with nearly 80 years of experience providing health insurance and benefits plan administration to private and government members. It operates four divisions—Government Services (administering Medicare, Medicaid, and military health benefits), Health Plan (offering individual, family, employer insurance and Medicare supplement plans), Data Logistics (secure document handling services like printing, mailing, scanning, digitizing, shredding), and New Ventures (investing in startups and entering new markets). The company also partners with nonprofits to support mental health and wellbeing for veterans, military members, women, and children.

📋 Description

• 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

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