Wisconsin Licensed Appeals Nurse

Job Summary

To support the appeals process, the full-time remote Wisconsin Licensed Appeals Nurse will examine medical records and claims for first-level appeal cases, ensuring compliance with Medicare guidelines and collaborating with Appeals Examiners to facilitate timely redeterminations.

Key responsibilities

• Review and assess first-level appeal cases for denied services, ensuring all medical documentation is complete
• Conduct comprehensive medical record reviews to determine clinical necessity and prepare written appeal letters
• Ensure timely follow-up on all appeals and maintain compliance with healthcare regulations and policies

Required qualifications

• Associate's (ASN) or Bachelor's Degree in Nursing (BSN)
• Active RN license in good standing applicable to state of practice
• One (1) or more years of clinical experience in a healthcare setting
• Basic knowledge of medical/clinical review processes, including Appeals and Utilization Review
• Solid computer skills with experience in online systems such as MS Outlook, Teams, and Word