Nurse

• Review and assess first-level appeal cases for denied services
• Ensure relevant medical documentation, coding, and clinical information support each appeal
• Conduct comprehensive medical record reviews to determine clinical necessity of services
• Make recommendations for resolution based on clinical guidelines, policy, and medical necessity of care
• Prepare and submit written appeal letters with comprehensive rationales and supporting clinical evidence
• Follow up on appeals and ensure proper resolution in accordance with company policies and external regulations
• Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process
• Work with and provide direction to Redetermination Representatives
• Ensure clinically determined redeterminations are responded to within CMS quality and timeline standards
• Collaborate with Appeals Examiners/Reps to complete medical reviews and redeterminations timely

Explore Appeals Nurse at WPS. Review requirements and application details.

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Appeals Nurse