Job description

Role Overview

The Medical Review Nurse Analyst performs detailed clinical examinations of medical documentation to verify adherence to regulatory standards and payer policies, ensuring proper billing and reimbursement. This role involves scrutinizing claims based on Medicare regulations and educating providers on billing and documentation compliance.

Salary and Location

The salary for this position ranges from 68000 to 72000 annually, with exact compensation influenced by the applicant's experience and expertise. Remote work is permitted for candidates based in specified states, including South Carolina and others.

Key Responsibilities

Conduct thorough assessments of medical records to confirm the necessity of services provided.
Review claims to ensure services billed correspond to Medicare requirements and that providers receive appropriate reimbursements when documentation validates the service.
Create clear clinical summaries detailing decisions to approve, deny, or modify claims.
Offer provider education aligned with the Targeted Probe and Educate (TPE) program.
Track provider progress and reinforce current billing and documentation standards.
Maintain compliance with federal, state, CMS, and corporate policies.
Stay informed about updates in clinical guidelines and medical policies.

Qualifications

An Associate's (ASN) or Bachelor's (BSN) degree in Nursing.
Active and valid Registered Nurse (RN) license for the practicing state.
Minimum of one year clinical experience in environments such as hospitals, homecare, or skilled nursing facilities.
Strong communication skills for effectively conveying complex medical information.
Detail-oriented with excellent organizational abilities to handle multiple cases.
Working knowledge of clinical review procedures.
Computer proficiency with experience in MS Outlook, Teams, OneNote, Word, and Excel.

Preferred Skills

Experience with Medicare Administrative Contractors (MAC).
Basic understanding or prior experience related to Medicare.

Remote Work Requirements

A wired ethernet connection linking the router to the computer.
High-speed cable or fiber internet with minimum speeds of 10 Mbps downstream and 1 Mbps upstream.

Employee Benefits

Option for remote working.
Opportunities for performance bonuses and merit increases.
401(k) plan with immediate full vesting and employer matching contributions.
Generous paid time off benefits.
Comprehensive health, dental, and telehealth coverage starting from day one.
Access to professional and leadership growth programs.

About the Employer

WPS is a reputable not-for-profit health insurance organization and government contractor headquartered in Madison, Wisconsin, serving Medicare beneficiaries and military personnel with comprehensive health insurance products and claims processing for nearly eight decades.

Company Culture

The company promotes an inclusive and empowering work environment that values diversity and employee engagement to foster innovation and high performance, recognized by multiple workplace awards.

Compliance and Screening

This position complies with CMS contract regulations and internal policies regarding data privacy and program integrity. It requires background checks and fingerprinting before system access is granted to protect sensitive information.