Medical Review Nurse Analyst

Role Snapshot  
 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  
68,000-72,000
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: 
Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin 

How do I know this opportunity is right for me?  If you enjoy the following:  

• Perform detailed reviews of medical records and documentation to determine the medical necessity of services. 

• 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. 

Minimum Qualifications  

• 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. 

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 work option 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 

• Professional and Leadership Development Programs  

• Review additional benefits: (https://www.wpshealthsolutions.com/careers/)  

Who We Are 

WPS, a health solutions company, is 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 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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Medicare (GHA) 

This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s).  As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services