Appeals Nurse

This is a fully remote position, open to applicants in Colorado, +14 more states.

📋 Description

• Evaluate and analyze first-level appeal cases for services that have been denied.

• Ensure that all pertinent medical documentation, coding, and clinical data substantiate each appeal.

• Conduct thorough reviews of medical records to assess the clinical necessity of the services rendered.

• Provide recommendations for resolution based on clinical guidelines, policies, and the medical necessity of care.

• Draft and submit written appeal letters that include comprehensive justifications and supporting clinical evidence.

• Follow up on appeals and ensure appropriate resolutions in line with company policies and external regulations.

• Stay informed about healthcare laws, regulations, and policies that pertain to the appeals process.

• Collaborate with and guide Redetermination Representatives.

• Ensure that clinically determined redeterminations are addressed within the quality and timeline standards set by CMS.

• Work together with Appeals Examiners/Reps to ensure timely completion of medical reviews and redeterminations.

⛳️ Requirements

• Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).

• Active RN license in good standing, applicable to the state of practice.

• A minimum of one (1) year of clinical experience in a healthcare environment (hospital/bedside, case management, MDS/Skilled Nursing, etc.).

• Exceptional written and verbal communication skills, with the ability to convey complex medical information in a clear and concise manner.

• Strong attention to detail and organizational abilities to handle multiple cases at once.

• Fundamental knowledge and understanding of medical/clinical review processes (e.g., Appeals/Utilization Review).

• Proficient computer skills with experience utilizing multiple online systems including MS Outlook, Teams, OneNote, Word, and Excel.

• Preferred experience working for a Medicare Administrative Contractor (MAC).

• Preferred one (1) year or more of experience in Medical Management, Medical Review, Utilization Management/Review, or Appeals.

• Basic knowledge of Medicare and/or relevant experience preferred.

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

• High-speed cable or fiber internet connection.

• Minimum internet connection of 10 Mbps downstream and at least 1 Mbps upstream.

• Compliance with applicable federal regulations, CMS contract requirements, and WPS internal policies, including data security, privacy, confidentiality, and program integrity standards.

• Subject to screening and background investigation, including fingerprinting, prior to accessing information systems and/or sensitive data.

🏝️ Benefits

• Options for remote and hybrid work arrangements.

• Opportunities for performance bonuses and/or merit increases.

• 401(k) plan with a 100% match for the first 3% of your salary and a 50% match for the next 2%, fully vested immediately.

• Competitive paid time off.

• Health insurance, dental insurance, and telehealth services begin on DAY 1.

• Opportunities for professional and leadership development programs.