Medical Review Nurse Analyst
About the role
The Medical Review Nurse Analyst is responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines. This role ensures that providers are billing and being paid appropriately for services provided based on Medicare guidelines.
Responsibilities
- Review submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines.
- Ensure Medicare providers are correctly reimbursed when documentation supports services rendered.
- Prepare written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
- Educate providers in accordance with the Targeted Probe and Educate (TPE) program.
- Monitor the progress of assigned providers and educate on current billing and documentation requirements.
- Ensure compliance with federal and state regulations, CMS guidelines, and company policies.
- Stay current on clinical guidelines, medical policy updates, and industry best practices.
Requirements
- Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).
- Active RN license, applicable to state of practice in good standing.
- One (1) or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.).
- Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
- Strong attention to detail and organizational skills to manage multiple cases simultaneously.
- Basic knowledge and understanding of medical/clinical review processes.
- Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.
Preferred Qualifications
- Experience working for a Medicare Administrative Contractor (MAC) preferred.
- Basic Medicare knowledge and/or experience preferred.
Benefits
- Performance bonus and/or merit increase opportunities
- 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
- Competitive paid time off
- Health insurance, dental insurance, and telehealth services start DAY 1
- Professional and Leadership Development Programs
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).
Who We Are
We are a health solutions company, a leading not-for-profit health insurer and federal government contractor headquartered in Madison, 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 has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.
Culture
This results in people bringing their authentic selves to work every day in an 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
Contact Us
To apply for this position, please visit our careers page: https://www.wpshealthsolutions.com/careers/