Job description

Role Overview

The Medical Review Nurse Analyst is tasked with evaluating medical records to confirm they meet regulatory and payer standards. This position verifies that healthcare providers are billing appropriately according to Medicare criteria, ensuring accurate payments for provided services. The nurse analyst also reviews claims and educates providers on proper billing and documentation practices.

Key Responsibilities

Conduct thorough examinations of medical documentation to assess the necessity of medical services.
Validate submitted claims for medical necessity and accurate coding per Medicare guidelines, ensuring correct reimbursement.
Generate clinical summaries and determinations that clearly explain approval, denial, or modification decisions.
Provide education to providers guided by the Targeted Probe and Educate (TPE) program.
Monitor assigned providers' progress and inform them about current billing and documentation standards.
Ensure strict adherence to federal, state regulations, CMS policies, and company protocols.
Keep updated on clinical guidelines, medical policies, and industry developments.

Qualifications

Associate or Bachelor’s Degree in Nursing (ASN or BSN).
Active Registered Nurse (RN) license valid in the practicing state and in good standing.
Minimum of one year clinical experience in healthcare settings such as hospitals, home care, or skilled nursing.
Strong communication skills capable of conveying complex medical information clearly.
Detail-oriented with excellent organizational skills for managing multiple cases concurrently.
Basic understanding of medical review procedures.
Proficient computer skills, including familiarity with MS Outlook, Teams, OneNote, Word, and Excel.

Preferred Skills

Experience with Medicare Administrative Contractor (MAC) operations.
Foundational Medicare knowledge or relevant experience is advantageous.

Remote Work Requirements

Wired Ethernet connection linking your router directly to the computer.
High-speed cable or fiber internet access.
Internet speed of minimum 10 Mbps download and 1 Mbps upload.
Additional information is available in the Remote Worker FAQ documentation.

Compensation and Benefits

Base salary range of $68,000 to $72,000, varying with experience and skills.
Opportunity for performance bonuses and merit raises.
401(k) plan with full match for the first 3% and 50% match for the next 2% of salary, fully vested immediately.
Generous paid time off.
Health, dental insurance, and telehealth services effective from the first day.
Access to professional and leadership development programs.

Company Background

WPS is a not-for-profit health insurance provider and federal contractor located in Madison, Wisconsin. They offer health insurance for individuals and groups, process Medicare claims, and support military personnel benefits nationwide. With nearly 80 years of experience, WPS is committed to simplifying healthcare and values a culture that promotes innovation, inclusion, and an engaging workplace.

Compliance and Security

This role supports CMS contracts and is subject to all related federal regulations, security standards, and background screening processes including fingerprinting to protect sensitive data and resources.