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.

Salary Range

$66,000 - $68,000

The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

Work Location

We are open to remote work 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

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.
• Excel at analyzing information and critical thinking to make sound medical decisions.
• A highly organized and adept at researching and finding answers independently using all available resources.
• Thrive 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, One Note, Word, and Excel.
• Are self-motivated and work with a great degree of independence.
• Are looking for a full-time, permanent position.

What will I gain 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 Hyland 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 continuous performance feedback environment.

Minimum Qualifications

• Associate's Degree in Nursing (ASN) or Bachelor's Degree in Nursing (BSN).
• Active RN license, applicable to state of practice in good standing.
• 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, One Note, Word, and Excel.

Preferred Qualifications

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

Remote Work Requirements

• Wired (ethernet cable) internet connection from your router to your computer
• High speed cable or fiber internet
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at )
• 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 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
• Employee Resource Groups
• Professional and Leadership Development Programs
• Review additional benefits: ()

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 current and future-to effectively seek, leverage, 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…