Job description

Job Overview

The Medical Review Nurse Analyst plays a critical role in evaluating medical records to verify adherence to regulatory and payer standards, primarily focusing on Medicare compliance. This position involves scrutinizing claims to confirm that billing aligns correctly with provided services and offers educational support to providers on necessary documentation and billing practices.

Key Responsibilities

Conduct thorough examinations of medical records and related documentation to assess the medical necessity of healthcare services.
Verify that claims submitted comply with Medicare guidelines, ensuring proper reimbursement based on supported services.
Compile clear and concise written clinical summaries explaining decisions regarding approvals, denials, or adjustments.
Deliver provider education consistent with the Targeted Probe and Educate (TPE) initiative.
Monitor provider compliance and progress, educating them on current standards for billing and documentation.
Ensure all activities comply with applicable federal and state regulations, CMS guidelines, and company policies.
Keep updated on evolving clinical guidelines, medical policies, and best industry practices.

Qualifications and Skills

Associate (ASN) or Bachelor of Science in Nursing (BSN) degree.
Active Registered Nurse (RN) license valid in the practicing state, with a clean standing status.
Minimum of one year clinical experience in healthcare environments such as hospitals, homecare, or skilled nursing.
Excellent communication abilities to clearly convey complex medical information in writing and speech.
Strong attention to detail and organizational capabilities to efficiently handle multiple cases simultaneously.
Foundational understanding of medical and clinical review protocols.
Proficient computer skills, including use of MS Outlook, Teams, OneNote, Word, and Excel.

Preferred Experience

Background in Medicare Administrative Contractor (MAC) operations.
Basic familiarity with Medicare rules and procedures.

Remote Work Requirements

Must have a wired Ethernet connection from router to computer.
High-speed cable or fiber internet connection required.
Internet speed minimums of 10 Mbps download and 1 Mbps upload.

Benefits

Option for remote work.
Eligibility for performance-based bonuses and merit increases.
401(k) plan with immediate vesting and company match up to 5% of salary.
Competitive paid time off.
Health, dental, and telehealth coverage starting on the first day.
Opportunities for professional growth and leadership development.

Additional Information

This role supports services under CMS contracts and is subject to federal regulations, CMS requirements, and internal policies related to data security, confidentiality, and program integrity. Candidates must undergo screening and background checks, including fingerprinting, prior to system access.

About the Employer

WPS is a not-for-profit health insurer and federal contractor with nearly 80 years of service. Based in Madison, Wisconsin, the company provides health insurance plans for a diverse clientele and manages benefits for millions of active-duty and retired military personnel nationally and internationally. WPS is committed to fostering an inclusive workplace culture that values employee engagement and innovation.