Appeals Nurse Remote

JOB REQUIREMENTS: 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. 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... For full info follow application link. Wisconsin Physicians Service Insurance Corporation is an Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities employer. ***** APPLICATION INSTRUCTIONS: Apply Online: ipc.us/t/32A6985847B64043 Qualified females, minorities, and special disabled veterans and other veterans are encouraged to apply.