Medical Review Nurse Analyst

Role Overview

The Medical Review Nurse Analyst performs clinical examinations of medical records to verify adherence to regulatory standards and payer policies. This position ensures that healthcare providers' billing and reimbursement align with Medicare regulations. It includes evaluating claims and educating providers on appropriate billing and documentation procedures.

Salary Details

The compensation for this role ranges from $68,000 to $72,000 annually, varying according to the candidate’s experience and expertise.

Work Location

This role supports remote work from selected states including Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, and Wisconsin.

Key Responsibilities

• Thoroughly review patient medical records and related documentation to assess medical necessity for services rendered.
• Analyze claims submissions to confirm services billed are medically justified and accurately coded following Medicare rules.
• Provide clear written clinical summaries supporting approvals, denials, or changes to claims.
• Deliver provider education in line with the Targeted Probe and Educate program requirements.
• Track provider progress and deliver updates on billing and documentation standards.
• Ensure compliance with applicable CMS directives, federal and state regulations, and organizational policies.
• Maintain current knowledge of clinical protocols, policy updates, and best practices within the healthcare sector.

Required Qualifications

• Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
• Active and valid Registered Nurse license for the practicing state.
• Minimum of one year clinical experience within healthcare environments such as hospitals, skilled nursing facilities, or home care.
• Exceptional written and verbal communication skills capable of clearly conveying complex medical concepts.
• Strong organizational skills with the ability to manage multiple concurrent cases precisely.
• Working understanding of clinical review methodologies.
• Proficiency with computers including applications like MS Outlook, Teams, OneNote, Word, and Excel.

Preferred Qualifications

• Experience working with Medicare Administrative Contractors is ideal.
• Basic knowledge of Medicare policies and processes is advantageous.

Remote Work Requirements

• Require a wired Ethernet connection from router to computer.
• High-speed internet service (cable or fiber) with at least 10 Mbps download and 1 Mbps upload speeds.

Benefits

• Option to work remotely.
• Potential eligibility for performance bonuses and merit-based raises.
• Competitive 401(k) plan including up to 100% match on initial 3% salary contributions and 50% match on the following 2%, fully vested immediately.
• Generous paid time off policies.
• Health, dental, and telehealth insurance coverage effective from day one.
• Opportunities for professional and leadership development.

About the Employer

WPS is a health solutions provider and federal contractor headquartered in Madison, Wisconsin, chiefly serving Medicare beneficiaries and military personnel. The company has provided healthcare-related support for nearly 80 years, emphasizing a culture of employee engagement and continual innovation.

Compliance and Security

This position supports Centers for Medicare & Medicaid Services contracts and is subject to federal regulations and internal policies regarding data privacy and program integrity, including background checks and fingerprinting prior to granting access to sensitive systems.