Medical Review Nurse Analyst

Role Overview

The Medical Review Nurse Analyst is tasked with performing thorough clinical evaluations of medical records to verify adherence to regulatory and payer standards. This position ensures proper billing and payment practices aligned with Medicare guidelines, involving claim analysis and educating providers on current requirements for billing and documentation.

Key Responsibilities

• Conduct detailed assessments of medical records and documentation to confirm medical necessity of services provided.
• Examine submitted claims to verify accurate coding and medical justification according to Medicare rules, ensuring appropriate reimbursement to providers when documentation substantiates rendered services.
• Generate written clinical summaries and decision rationales regarding approvals, denials, or claim modifications.
• Deliver educational sessions to providers consistent with the Targeted Probe and Educate program.
• Track and support the progress of designated providers, updating them on the latest billing and documentation standards.
• Maintain compliance with federal/state regulations, CMS policies, and organizational guidelines.
• Stay informed on updated clinical policies, medical rules, and best industry standards.

Minimum Qualifications

• Associate Degree in Nursing (ASN) or Bachelor of Science in Nursing (BSN).
• Currently active and good standing Registered Nurse (RN) license valid for the practicing state.
• At least one year of clinical experience in healthcare environments such as hospitals, home care, or skilled nursing facilities.
• Proficient written and oral communication skills to clearly explain complex medical information.
• Exceptional attention to detail and organizational ability to manage numerous cases concurrently.
• Basic understanding of medical/clinical review practices.
• Competent computer skills with experience using multiple online platforms including Microsoft Outlook, Teams, OneNote, Word, and Excel.

Preferred Qualifications

• Prior experience within a Medicare Administrative Contractor (MAC) setting is advantageous.
• Familiarity with Medicare policies and processes is preferred.

Remote Work Criteria

• Secure wired Ethernet internet connection directly from router to computer.
• High-speed internet via cable or fiber.
• Minimum internet speeds of 10 Mbps download and 1 Mbps upload.

Compensation

The annual salary ranges from $68,000 to $72,000, with variations based on qualifications and expertise.

Benefits

• Flexible remote work options.
• Opportunities for performance bonuses and merit-based increases.
• 401(k) retirement plan featuring full match on the first 3% of salary and half match on the next 2%, with immediate 100% vesting.
• Competitive paid time off policies.
• Health, dental insurance, and telehealth services starting from day one.
• Access to professional development and leadership training programs.

About the Company

WPS is a non-profit health insurer and a federal government contractor headquartered in Madison, Wisconsin. Operating for almost 80 years, WPS offers diverse health insurance plans and manages benefits for Medicare beneficiaries, active-duty military, and veterans. The company maintains a workplace culture that encourages innovation, inclusion, and employee engagement, fostering adaptability and authentic expression at work.

Compliance

This role supports CMS contracts and is therefore subject to all applicable federal regulations and company policies regarding data security, privacy, confidentiality, and program integrity. Personnel will undergo background checks and fingerprinting to ensure government data protection.