Title: Appeals Nurse

(RN) - Remote

Location: WI-Madison

Job Description: Description

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.

Salary Range

$66,000 to $68,000The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills and experience.
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&#39;s military, veterans, Guard and Reserves, and Medicare beneficiaries.
Working in a continuous performance feedback environment.

Minimum Qualifications

Associate&#39;s (ASN) or Bachelor&#39;s Degree in Nursing (BSN).
Active RN license, applicable to state of practice in good standing.
1 or more years of experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals.

Preferred Qualifications

1 or more years of previous experience working for another Medicare Administrative Contractor (MAC).
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.
Experience working in a remote work environment.

Work Location

We are open to remote work in the following approved 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, Wisconsin

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 https://speedtest.net)

Please review Remote Worker FAQs (https://secure.wpsic.com/files/remote-work-faqs.pdf) for additional information

Benefits

Remote and hybrid work options available

Performance bonus and/or merit increase opportunities

401(k) with dollar-per-dollar match up to 6% of salary (100% vested immediately)

Competitive paid time off

Health insurance, dental insurance, and telehealth services start DAY 1

Employee Resource Groups

Professional and Leadership Development Programs

Review additional benefits: ( https://www.wpshealthsolutions.com/careers/fulltime\_benefits.shtml )

Who We Are

WPS Health Solutions (https://www.wpshealthsolutions.com/about/index.shtml) 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 (https://www.wpshealthsolutions.com/75/) . Proud to be military and veteran ready.

Culture Drives Our Success

WPS' Culture is where the great work a nd innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce-both current and future-to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing t eams. This results in people bringing their authentic selves to work every day in a n organization that successfully adapts to business changes and new opportunities.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition (https://www.wpshealthsolutions.com/news/?c=awards)

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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

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