Medical Review Nurse Analyst

Role Overview

The Medical Review Nurse Analyst is tasked with performing detailed clinical evaluations of medical records to verify compliance with both regulatory standards and payer policies. This position ensures that healthcare providers' billing aligns accurately with Medicare guidelines and that reimbursements are appropriate for services rendered. Additionally, the role involves reviewing claims and providing educational support to providers concerning current billing and documentation protocols.

Key Responsibilities

• Conduct comprehensive reviews of medical documentation to assess the medical necessity of services and verify appropriate coding.
• Analyze submitted claims to confirm medical necessity and adherence to Medicare rules, ensuring correct reimbursement.
• Document clinical findings and decisions clearly in written summaries, detailing rationales for approvals, denials, or changes.
• Deliver provider education as part of the Targeted Probe and Educate (TPE) initiative.
• Track and guide assigned providers on updated billing and documentation standards.
• Maintain compliance with federal, state, CMS regulations, and internal policies.
• Stay updated on clinical guidelines, medical policy changes, and industry best practices.

Qualifications

• Associate's Degree in Nursing (ASN) or Bachelor's Degree in Nursing (BSN) required.
• Active Registered Nurse license valid in practicing state and in good standing.
• At least one year of clinical experience in healthcare environments such as hospitals, homecare, or skilled nursing facilities.
• Excellent communication skills, capable of conveying complex medical data clearly both in writing and verbally.
• Strong attention to detail and ability to handle multiple cases effectively.
• Basic understanding of medical and clinical review processes.
• Proficient with computer applications including MS Outlook, Teams, OneNote, Word, and Excel.
• Preferred: Experience with Medicare Administrative Contractors (MAC) and foundational Medicare knowledge.

Remote Work Requirements

• Direct wired Ethernet connection from router to computer.
• High-speed cable or fiber internet service.
• Internet speed minimums of 10 Mbps download and 1 Mbps upload.

Compensation and Benefits

• Annual salary range: $68,000 to $72,000, varying by experience and skills.
• Remote working option within approved states including Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, and Wisconsin.
• Potential bonuses and merit-based salary increases.
• 401(k) plan with immediate full vesting: 100% match on first 3% of contributions, 50% match on next 2%.
• Competitive paid leave policies.
• Comprehensive health, dental, and telehealth insurance commencing on day one.
• Access to professional and leadership development opportunities.

Company Background

WPS is a not-for-profit health insurer and federal government contractor with nearly 80 years of service excellence. Headquartered in Madison, Wisconsin, WPS administers health insurance plans for individuals, families, and groups, including Medicare beneficiaries and active/retired military personnel across the US and internationally. The company prides itself on its military and veteran readiness and fostering an inclusive, empowered workplace culture that embraces diversity and supports continuous innovation.

Additional Information

This role operates under the Centers for Medicare & Medicaid Services (CMS) contract(s), adhering strictly to federal regulations, CMS mandates, and company standards on data security and confidentiality. Candidates must pass screening, including background checks and fingerprinting, to access sensitive information and secure government systems.