Nurse Specialist for Appeals Evaluation

Join our dynamic team as an Appeals Nurse! In this essential role, you will meticulously evaluate medical records and claims for initial appeals, assessing the medical necessity of services while ensuring adherence to Medicare coverage guidelines and regulations. You will work collaboratively with Appeals Examiners and Representatives, enabling the timely completion of medically reviewed redeterminations. Salary Range: $66,000 - $68,000 The offered base pay for this position may vary depending on your job-related knowledge, skills, and experience. Work Location: This position allows for 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. Could this opportunity be a perfect fit for you? If you: Have moved away from direct patient care but wish to leverage your nursing expertise in a new setting. Excel at information analysis and apply critical thinking for informed medical decisions. Are organized and adept at independent research. Thrive in a performance-driven environment focused on quality and productivity. Possess strong technical writing skills. Prefer daytime hours without on-call duties and enjoy holidays off. Are tech-savvy, proficient in MS Outlook, Teams, OneNote, Word, and Excel. Are self-motivated and capable of working independently. Are looking for a full-time, permanent role. What will you gain from this role? Opportunities to collaborate with a variety of healthcare professionals, both clinical and non-clinical. Experience with systems like the Medicare Appeal System and Hyland OnBase tool. Participate in the care of military personnel, veterans, and Medicare beneficiaries. Engage in a feedback-rich environment that fosters your professional growth. Minimum Qualifications: Associate's Degree in Nursing (ASN) or Bachelor's Degree in Nursing (BSN). Active RN license in good standing for applicable state practice. At least 1 year of clinical experience in a healthcare setting (hospital, bedside, case management, MDS/Skilled Nursing, etc.). Exceptional written and verbal communication skills for conveying complex medical information. Strong attention to detail and organizational skills to effectively manage multiple cases. Basic knowledge of medical review processes such as Appeals and Utilization Review. Solid computer skills, with proficiency in various online systems. Preferred Qualifications: Experience with a Medicare Administrative Contractor (MAC). At least 1 year of experience in Medical Management, Medical Review, Utilization Management, or Appeals. Basic understanding of Medicare operations and processes. Remote Work Requirements: Wired internet connection (ethernet cable) from your router to your computer. High-speed cable or fiber internet connection. Minimum internet speeds of 10 Mbps downstream and 1 Mbps upstream. Benefits: Remote and hybrid work opportunities available. Performance-based bonuses and merit increases. 401(k) plan with generous employer matching (fully vested immediately). Competitive paid time off package. Health, dental insurance, and telehealth services available from Day 1. Access to professional and leadership development programs. Who We Are: WPS Health Solutions is a leading not-for-profit health insurer and a federal government contractor based in Wisconsin. We provide health insurance plans for individuals, families, seniors, and group health plans for various businesses. Our services encompass claims processing and support for Medicare beneficiaries, along with managing benefits for military personnel and veterans. Our Culture: At WPS, we value employee engagement, innovation, and diverse perspectives, creating a vibrant and rewarding workplace. We have received recognition for our achievements in fostering a positive work environment. This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s), subject to applicable federal regulations and WPS internal policies. An Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.

Created: 2026-03-04