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 denied services.

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

• Perform thorough medical record reviews to ascertain the clinical necessity of services.

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

• Draft and submit written appeal letters containing comprehensive rationales and supporting clinical evidence.

• Follow up on appeals to 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 offer guidance to Redetermination Representatives.

• Ensure that clinically determined redeterminations are addressed within CMS quality standards and timelines.

• Work together with Appeals Examiners/Reps to conduct medical reviews and redeterminations promptly.

⛳️ Requirements

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

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

• One (1) or more years of clinical experience in a healthcare environment (hospital/bedside, case management, MDS/Skilled Nursing, etc.).

• Exceptional written and verbal communication skills, capable of conveying complex medical information clearly and succinctly.

• Strong attention to detail and organizational abilities to manage multiple cases effectively.

• Basic understanding of medical/clinical review processes (i.e., Appeals/Utilization Review).

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

• Experience working for a Medicare Administrative Contractor (MAC) is preferred.

• One (1) or more years of experience in Medical Management, Medical Review, Utilization Management/Review, or Appeals is preferred.

• Basic knowledge and/or experience with Medicare is 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.

• 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% (100% vested immediately).

• Competitive paid time off.

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

• Professional and Leadership Development Programs.