Appeals Nurse

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

$66,000 - $68,000; base pay varies within this range based on job‑related knowledge, skills, and experience.

Remote work is accepted 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.

• Collaborating with a team of clinicians and non‑clinicians.
• Learning a variety of systems, including the Medicare Appeal System (MAS) and the Hyland OnBase tool.
• Experience working for a nation’s military, veterans, Guard and Reserves, and Medicare beneficiaries.
• Working in a continuous performance feedback environment.

• 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 or more years of clinical experience in a healthcare setting.
• 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 (Appeals/Utilization Review).
• Solid computer skills with experience in multiple online systems including MS Outlook, Teams, One Note, Word, and Excel.

• Experience working for a Medicare Administrative Contractor (MAC).
• 1 or more years of experience in Medical Management, Medical Review, Utilization Management/Review, or Appeals.
• Basic Medicare knowledge and/or experience.

• Wired (ethernet cable) internet connection from your router to your computer.
• High‑speed cable or fiber internet.
• Minimum 10 Mbps downstream and at least 1 Mbps upstream internet connection (verify at ).
• 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 % (100 % vested immediately).
• Competitive paid time off.
• Health, dental, and telehealth services starting DAY 1.
• Employee Resource Groups.
• Professional and Leadership Development Programs.
• Additional benefits overview:
  Benefits Page.

WPS Health Solutions is a leading not‑for‑profit health insurer and federal government contractor headquartered in Wisconsin, offering plans for individuals, families, seniors, and businesses. We process claims and provide customer support for Medicare beneficiaries and manage benefits for millions of active‑duty and retired military personnel worldwide.

Our culture fosters innovation and employee engagement, rewarding high‑performing teams and encouraging diverse perspectives. We have earned numerous awards for workplace culture and continuously adapt to business opportunities.

This position is part of CMS contracts and requires compliance with federal regulations, CMS contract requirements, and WPS internal policies. All personnel are subject to background investigations and security protocols before accessing sensitive information.