Appeals Nurse

Appeals Nurse

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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 and Reps to ensure redeterminations are medically reviewed as needed and completed timely.

$66,000 – $68,000

Remote work in the following approved states:
Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin

• 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.
• A 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 Мне strength in technical writing.
• Desire day hours with no on‑call work and holidays off.
• Are technically strong on computers including MS Outlook, Teams, One Note, Word, and Excel.
• Are self‑motivated and work with a great degree of independence.
• Are looking for a full‑time, permanent position.

• Collaborating with a team of clinicians and non‑clinicians.
• Learning a variety of systems, including but not limited to the Medicare Appeal System (MAS) and the Hyland OnBase tool 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诚信 feedback environment.

• Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
• Active RN license in good standing, applicable to state of practice.
• At least 1 year of clinical experience in a healthcare setting.
• Excellent written and verbal communication skills, with the ability to convey complex medical information clearly and concisely.
• Strong attention to detail and organizational skills to manage multiple cases simultaneously.
• Basic knowledge of medical/clinical review processes (i.e., Appeals/Utilization Review).
• Solid computer skills with experience in MS Outlook, Teams, One Note, Word, and Excel.

• Experience working for a Medicare Administrative Contractor (MAC).
• At least 1 year of experience in Medical Management, Medical Review, Utilization Management/Review, or Appeals.
• Basic Medicare knowledge and/or experience.

• 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.

• Remote and hybrid work options available.
• Performance bonus and/or merit increase opportunities.
• 401(k) with a 100% match for the first สินค้า 3% of your salary and a 50% match for the next 2% (100% vested immediately).
• Competitive paid time off.
• Health, dental, and telehealth insurance starting DAY 1.
• Employee Resource Groups.
• Professional and Leadership Development Programs.
• Additional benefits details available at

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.

WPS’ Culture emphasizes open and empowering employee experiences, fostering engagement and innovation for high‑performing teams.

This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services.