Appeals Nurse

WPS

. Review and assess first-level appeal cases for denied services .

Posted 11/2/2026full-timeRemote • United StatesJunior💰 $66,000 - $68,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical record reviews, appeals processes, and clinical necessity assessments, while ensuring compliance with healthcare regulations and effective communication of complex medical information.

Highest-signal resume keywords

Active RN LicenseClinical Experience in HealthcareMedical Review ProcessesExcellent Written and Verbal CommunicationExperience with Medicare Administrative Contractor

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewClinical Necessity AssessmentAppeals Process ManagementUtilization ReviewMedical ManagementAttention to DetailOrganizational SkillsBasic Medicare Knowledge

Soft Skills

Strong Communication Skills

Tools & Technologies

MS OutlookMS TeamsMS OneNoteMS WordMS Excel

Certifications & Qualifications

Associate’s Degree in NursingBachelor’s Degree in Nursing

Industry Keywords

Healthcare RegulationsCMS Quality StandardsData SecurityPrivacyConfidentiality

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

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 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, OneNote, Word, and Excel
Experience working for a Medicare Administrative Contractor (MAC) preferred
One (1) or more years of experience working in Medical Management, Medical Review, Utilization Management/Review, or Appeals preferred
Basic Medicare knowledge and/or experience 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

Comp & perks

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
Professional and Leadership Development Programs