Medical Review Nurse Analyst

Role Overview

The Medical Review Nurse Analyst conducts thorough clinical evaluations of medical records to verify compliance with regulatory and payer standards. This position ensures accurate billing and reimbursement for services rendered in accordance with Medicare guidelines. The role involves reviewing claims and providing educational guidance to healthcare providers regarding current billing and documentation requirements.

Key Responsibilities

• Perform in-depth reviews of medical records and documentation to determine medical necessity of services.
• Evaluate submitted claims to confirm billed services are medically necessary and appropriately coded based on Medicare rules.
• Guarantee that Medicare providers are reimbursed correctly when documentation supports the services provided.
• Prepare detailed clinical summaries with clear justification for approvals, denials, or modifications.
• Provide education to providers in alignment with the Targeted Probe and Educate (TPE) program.
• Monitor progress of assigned providers and deliver updates on current billing and documentation standards.
• Ensure adherence to federal and state regulations, CMS guidelines, and company policies.
• Keep abreast of clinical guidelines, medical policy changes, and industry best practices.

Qualifications

• Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
• Active and valid RN license applicable to the state of practice without restrictions.
• Minimum of one year clinical experience in healthcare settings such as hospitals, homecare, or skilled nursing facilities.
• Excellent written and verbal communication skills capable of clearly explaining complex medical information.
• Strong attention to detail and organizational ability to manage multiple cases simultaneously.
• Foundational understanding of medical and clinical review procedures.
• Proficient computer skills including familiarity with MS Outlook, Teams, OneNote, Word, and Excel.

Preferred Skills

• Prior experience working with a Medicare Administrative Contractor (MAC) is desirable.
• Basic knowledge or experience with Medicare guidelines is preferred.

Remote Work Requirements

• A wired Ethernet connection from your router to your computer is mandatory.
• High-speed cable or fiber internet connection required.
• Internet speeds must be at least 10 Mbps downstream and 1 Mbps upstream.

Compensation & Benefits

• Annual salary range between $68,000 and $72,000, determined by experience and skills.
• Remote work flexibility available in specific approved states including Illinois and others.
• Opportunities for performance bonuses and merit increases.
• 401(k) plan with immediate vesting and employer matching contributions.
• Generous paid time off package.
• Health, dental, and telehealth coverage starting on the first day of employment.
• Access to professional and leadership development programs.

About WPS

WPS is a not-for-profit health insurer and federal government contractor based in Madison, Wisconsin, with nearly 80 years of experience providing health insurance plans and managing Medicare benefits for millions, including military personnel. The company values a culture of openness, employee engagement, and innovation, offering a supportive environment where diverse perspectives are encouraged.

Compliance and Security

This position operates under Centers for Medicare & Medicaid Services (CMS) contract regulations, necessitating adherence to all related federal policies including data security and confidentiality. Employees are subject to background checks and fingerprinting prior to accessing sensitive government systems and data.