Appeals Nurse (RN) – Remote

October 16, 2024

Job Description

Who We Are

WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide 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 Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready.

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Culture Drives Our Success

WPS’ Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive and empowering employee experience. We recognize the benefits of Diversity, Equity, and Inclusion as an investment in our workforce-both current and future-to effectively seek, leverage, and include diverse 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.

From 2021 to 2023, WPS Health Solutions was recognized for several awards:

Madison, Wisconsin’s Top Workplaces
USA Top Workplaces and the cultural excellence awards for Remote Work and Work-Life Flexibility
Achievers 50 Most Engaged Workplaces® with the further honor of Achievers “Elite 8” winner in the category of Culture Alignment
DAV Patriot Employer
VETS Indexes 4 Star Employer
BBB Torch Award for Ethics from Better Business Bureau of Wisconsin
Role Snapshot

Our Appeals Nurse will examine 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.In addition, this role will:

Utilize clinical knowledge and clinical review judgment to conduct medical review of claim documentation for first-level appeal cases.
Provide clear and concise written explanations for reason a specific claim or set of claims cannot be paid as a result of first-level redetermination.
Work with and provide direction to Redetermination Representatives to assure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards.
Analyze appeals and identify specific high-volume problem issues and relay information to Redeterminations Manager and Senior Analyst.
Participate in various workgroups for purposes of Continuous Quality Improvement (CQI) to promote consistent medical review of claim documentation and information.

How do I know this opportunity is right for me?If you:

Have moved away from direct patient care and want to continue using your nursing knowledge in a new and different way.
Excel at analyzing information and critical thinking to make sound medical decisions.
Are highly organized and adept at researching and finding answers independently using all available resources.
Thrive in a production environment where quality and production metrics are critical to individual and team success.
Have strength in technical writing.
Desire day hours with no on-call work and holidays off.
Are technically strong on computers including MS Outlook, Teams, OneNote, Word, and Excel.
Are self-motivated and work with a great degree of independence.
Are looking for a full-time, permanent position.

What will I gain from this role?

Collaborating with a team of clinicians and non-clinicians.
Learning a variety of systems, including but not limited to, the Medicare Appeal System (MAS) which is a content management system for Part A appeals and our Hyland OnBase tool which is our content management system used for Part B appeals.
Experience working in an environment that serves our nation’s military, veterans, Guard and Reserves, and Medicare beneficiaries.
Working in a continuous performance feedback environment.
Minimum Qualifications
Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN)
Active RN license, applicable to state of practice in good standing

Preferred Qualifications

Experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals
Strong technical writing skills
Strong computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.
4 or more years of experience in clinical nursing
Experience outside of direct patient care
Experience working with Medicare Part A and Part B
Previous experience working for another Medicare Administrative Contractor (MAC)
Experience working in a remote work environment
Remote Work Requirements
Wired (ethernet cable) internet connection from your router to your computer
High speed cable or fiber internet
Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at
Please review Remote Worker FAQs for additional information

Appeals Nurse (RN) – Remote

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