Remote Clinical Review Nurse – Medicare Appeals Specialist

Join WPS Health Solutions as a pivotal Remote Clinical Review Nurse – Medicare Appeals Specialist! We are seeking a highly skilled and dedicated Registered Nurse (RN) to join our growing team in a fully remote capacity. This is an exciting opportunity to leverage your clinical expertise and analytical abilities to ensure the accuracy and integrity of Medicare Part A and Part B appeals. Our state-of-the-art remote workspace provides a comfortable and productive environment for you to excel.

Who We Are: WPS Health Solutions

WPS Health Solutions is a leading not-for-profit health insurer and a trusted federal government contractor headquartered in Wisconsin. For over 75 years, we have been committed to making healthcare easier for the individuals and communities we serve. We provide comprehensive health insurance plans for individuals, families, seniors, and group health plans for businesses of all sizes. A significant portion of our work involves processing claims and providing vital customer support for Medicare beneficiaries, as well as managing benefits for millions of active-duty and retired military personnel across the U.S. and internationally. We are deeply proud of our strong connection to the military community and are committed to being a veteran-ready employer.

Our Culture: Driving Success Through People

At WPS, our culture is the foundation of our success. We foster an inclusive and empowering employee experience where innovation and collaboration thrive. We champion Diversity, Equity, and Inclusion as core values, recognizing that diverse perspectives are essential for agility and innovation. We believe in creating an environment where every employee feels valued and can bring their authentic selves to work. This commitment has been recognized through numerous accolades, including being named a top workplace in Madison, Wisconsin, and receiving national recognition for our remote work culture and employee engagement. We are proud to be a DAV Patriot Employer and a 4-Star Employer with VETS Indexes, as well as recognized for our ethical business practices by the Better Business Bureau.

Role Snapshot: Making a Difference in Medicare Appeals

As a Remote Clinical Review Nurse – Medicare Appeals Specialist, you will play a critical role in the first-level review of Medicare Part A and Part B appeals. Your expertise will be essential in examining medical records and claims information to determine if the services provided meet Medicare coverage guidelines and are medically necessary. Your key responsibilities will include:

• Conducting thorough medical reviews of claim documentation for first-level appeals, utilizing your clinical knowledge and judgment.
• Providing clear, concise, and legally sound written explanations for claim denials based on first-level redeeterminations.
• Collaborating with and providing guidance to Redetermination Representatives to ensure timely and accurate responses to appeals, adhering to CMS quality and timeline standards.
• Analyzing appeal trends to identify high-volume issue areas and proactively communicate findings to the Redeetermination Manager and Senior Analyst.
• Participating in continuous quality improvement (CQI) workgroups to enhance the consistency and quality of medical review processes.

Why This Opportunity is Right for You?

This role is an excellent fit if you:

• Are transitioning from direct patient care and seek to apply your nursing knowledge in a new and impactful way.
• Possess strong analytical and critical thinking skills to make sound medical decisions.
• Are highly organized, detail-oriented, and adept at independently researching and finding answers using various resources.
• Thrive in a production-focused environment with clear quality and productivity metrics.
• Have excellent technical writing skills to effectively communicate complex medical information.
• Prefer a role with standard day hours, no on-call responsibilities, and paid holidays off.
• Are proficient with computer applications, including Microsoft Outlook, Teams, OneNote, Word, and Excel.
• Are self-motivated, highly independent, and thrive in a remote work setting.
• Are seeking a full-time, permanent position with a stable and reputable organization.

What You Will Gain from This Role?

This position offers a rewarding opportunity to:

• Collaborate with a diverse team of clinicians and non-clinical professionals.
• Gain experience with various healthcare systems, including the Medicare Appeals System (MAS) for Part A appeals and our Hyland OnBase tool for Part B appeals.
• Work within an environment dedicated to serving our nation's military, veterans, Guard and Reserves, and Medicare beneficiaries.
• Participate in a continuous performance feedback process to support your professional growth.

Minimum Qualifications

To be considered for this position, you must meet the following minimum qualifications:

• An Associate's Degree in Nursing (ASN) or a Bachelor's Degree in Nursing (BSN).
• An active Registered Nurse (RN) license in a state that is in good standing.

Preferred Qualifications

The following qualifications are highly desirable:

• Prior experience in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals.
• Demonstrated strong technical writing skills.
• Proficiency with multiple online systems, including Microsoft Outlook, Teams, OneNote, Word, and Excel.
• Four or more years of experience in clinical nursing.
• Experience working outside of direct patient care settings.
• Specific experience with Medicare Part A and Part B regulations and processes.
• Previous experience working for another Medicare Administrative Contractor (MAC).
• Proven experience working effectively in a remote work environment.

Remote Work Requirements

To ensure seamless remote work, you must have:

• A wired (Ethernet cable) internet connection directly to your computer.
• High-speed cable or fiber internet service.
• A minimum internet connection speed of 10 Mbps down and 1 Mbps up (please verify your speed at https://speedtest.net).
• Agreement to review and adhere to the Remote Worker FAQs for additional information.

Salary Range

The base salary for this position ranges from $66,000 to $68,000 per year. Your specific starting salary within this range will be determined based on your qualifications, skills, and experience.

Work Schedule

This is a full-time, salaried position with a flexible work schedule. You will work Monday through Friday, with production hours between 6:00 AM and 6:00 PM Central Standard Time (CST). Flexibility in your daily start and end times is available, provided you work a total of 40 hours per week within these production hours. The initial training period is approximately 2 to 3 months and will be conducted remotely, typically Monday through Friday from 8:00 AM to 4:00 PM CST (hours may vary slightly).

Work Location

WPS Health Solutions is a remote-first organization and offers remote work in the following states: Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, and Wisconsin.

Benefits

We offer a comprehensive benefits package, including:

• A fully remote work option.
• Performance bonus and/or merit increase opportunities.
• A generous 401(k) plan with a dollar-per-dollar match up to 6% of your salary (fully vested immediately).
• Competitive paid time off.
• Comprehensive health, dental, and telehealth insurance coverage starting on your first day of employment.
• Employee Resource Groups.
• Professional and leadership development programs.
• Review additional benefits details here.

Ready to Apply?

If you are a highly motivated and skilled clinical nurse looking for a rewarding remote career, we encourage you to apply! We are excited to review your application.