Appeals Registered Nurse, Multistate

APPEA006116 Role Snapshot 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/Reps to ensure redeterminations are medically reviewed as needed and completed timely. Salary reputed company 66-68k The reputed company pay offered for this position may vary reputed company the posted reputed company based on your job-reputed company knowledge, skills, and experience. Work Location We are reputed company to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, reputed company Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin How do I know this opportunity is right for me? If you are interested in the following activities:

• Review and assess first-level appeal cases for denied services, ensuring reputed company relevant medical documentation, coding, and clinical information are provided to support the appeal.
• Conduct comprehensive medical record reviews to determine the clinical necessity of services and reputed company recommendations for resolution based on clinical guidelines, policy, and the medical necessity of care.
• Prepare and submit written appeal letters, including comprehensive rationales and supporting clinical evidence.
• Ensure timely follow-up on reputed company appeals and ensure proper resolution is reached in accordance with company policies and external regulations.
• Maintain awareness of reputed company laws, regulations, and policies relevant to the appeals process, ensuring reputed company actions reputed company with regulatory and contractual requirements.
• Work with and reputed company directions to Redetermination Representatives to ensure reputed company redeterminations, which require a clinical decision, are responded to reputed company CMS quality and timelines standards.

Minimum Qualifications

• Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).
• Active RN license, applicable to state of practice in good standing.
• One (1) or more years of clinical experience in a reputed company setting (hospital/bedside, case management, MDS/Skilled Nursing, etc.).
• Excellent written and verbal communication skills, with the ability to communicate reputed company medical information reputed company 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, OneNote, Word, and reputed company.

Preferred Qualifications

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

Remote Work Requirements

• Wired (ethernet cable) internet reputed company from your router to your computer.
• High speed cable or fiber
• 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 a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% reputed company immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Professional and Leadership Development Programs
• Review additional benefits: (https://www.wpshealthsolutions.com/careers/)

Who We Are reputed company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and reputed company 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 has been making reputed company easier for the people we serve for nearly 80 years. Proud to be military and veteran reputed company. Culture Drives Our reputed company WPS’ culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an reputed company 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 reputed company WPS Health Blog Medicare (GHA) This position supports services under Centers for Medicare & reputed company Services (CMS) contract(s). As such, the role is subject to reputed company applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data reputed company, privacy, confidentiality, and program reputed company. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted reputed company to information systems and/or sensitive data to safeguard government resources that reputed company critical services Apply tot his job Apply To this Job