Medical Review Nurse Analyst

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. The Medical Review Nurse Analyst reviews claims and delivers provider education on current billing and documentation requirements.

Salary Range

$66,000 - $70,000

The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

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

How do I know this opportunity is right for me? You'll be:

• Reviewing submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines.
• Preparing written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
• Educating providers in accordance with the Targeted Probe and Educate (TPE) program.
• Monitoring the progress of assigned providers and educate on current billing and documentation requirements.
• Ensuring compliance with federal and state regulations, CMS guidelines, and company policies.
• Staying current on clinical guidelines, medical policy updates, and industry best practices.
  
  

What will I gain from this role?

• Enjoying a work from home position with daytime hours, no on-call work, no travel, and holidays off
• Collaborating with a team of both clinicians and non-clinicians
• Deepening your understanding of Medicare and how the program works
• Learning about our Hyland OnBase tool which is our content management system used for viewing electronic records
• Experience working in an environment that serves our Nation’s military, veterans, Guard and Reserves and Medicare beneficiaries
• Working in a continuous performance feedback environment
  
  

Minimum Qualifications

• Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
• Active RN license, applicable to state of practice in good standing.
• 1 or more years of clinical experience in a healthcare setting.
• 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).
• Basic Medicare knowledge and/or experience.
  
  

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 for additional information
  
  

Benefits

• Remote and hybrid work options available
• 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
• 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 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 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 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.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.

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