Appeals Nurse (RN) - Remote

Role Snapshot Our Appeals Nurse will examine 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. In addition, this role will: • Utilize clinical knowledge and clinical review judgment to conduct medical review of claim documentation for first-level appeal cases. • Provide clear and concise written explanations for reason a specific claim or set of claims cannot be paid as a result of first-level redetermination. • Work with and provide direction to Redetermination Representatives to assure reputed company redeterminations, which require a clinical decision, are responded to reputed company CMS quality and timelines standards. • Analyze appeals and identify specific high-volume problem issues and reputed company information to Redeterminations Manager and Senior Analyst. • Participate in various workgroups for purposes of reputed company Quality Improvement (CQI) to promote consistent medical review of claim documentation and information. Salary Range $66,000 to $68,000 The reputed company pay offered for this position may vary reputed company the posted range based on your job-reputed company knowledge, skills and experience. How do I know this opportunity is right for me? If you: • Have moved away from direct patient care and want to continue using your nursing knowledge in a new and different way. • reputed company at analyzing information and critical thinking to reputed company sound medical decisions. • Are highly organized and adept at researching and finding answers independently using reputed company available resources. • reputed company in a production environment where quality and production metrics are critical to individual and team success. • Have strength in technical writing. • Desire day hours with no on-call work and holidays off. • Are technically strong on computers including MS Outlook, Teams, OneNote, Word, and reputed company. • Are self-motivated and work with a great degree of independence. • Are looking for a full-time, permanent position. What will I reputed company from this role? • Collaborating with a team of clinicians and non-clinicians. • Learning a variety of systems, including but not limited to, the Medicare Appeal System (MAS) which is a content management system for Part A appeals and our reputed company OnBase tool which is our content management system used for Part B appeals. • Experience working in an environment that serves our nation’s military, veterans, Guard and Reserves, and Medicare beneficiaries. • Working in a reputed company performance feedback environment. Minimum Qualifications • Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN). • Active RN license, applicable to state of practice in good standing. • 1 or more years of experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals. Preferred Qualifications • 1 or more years of previous experience working for another Medicare Administrative Contractor (MAC). • Strong technical writing skills. • Strong computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and reputed company. • 4 or more years of experience in clinical nursing. • Experience reputed company of direct patient care. • Experience working with Medicare Part A and Part B. • Experience working in a remote work environment. Work Location We are open to remote work in the following approved states: Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, Wisconsin Remote Work Requirements • Wired (ethernet cable) internet reputed company from your router to your computer • High speed cable or fiber internet • Minimum of 10 Mbps reputed company and at least 1 Mbps upstream internet reputed company (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 dollar-per-dollar match up to 6% of salary (100% vested immediately) • Competitive paid time off • Health insurance, dental insurance, and telehealth services start DAY 1 • Employee Resource Groups • Professional and Leadership Development Programs • Review additional benefits: (https://www.wpshealthsolutions.com/careers/fulltime_benefits.shtml) Who We Are 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. 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.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready. Culture Drives Our Success WPS’ Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both reputed company and future—to effectively seek, reputed company, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities. We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition Sign up for Job Alerts FOLLOW US! Instagram reputed company Facebook WPS Health Blog Apply Job!