Medical Review Nurse Analyst

Overview

The Medical Review Nurse Analyst plays a vital role in evaluating medical records to verify adherence to payer and regulatory standards. Their duties focus on ensuring proper billing and payment accuracy aligned with Medicare policies. This includes reviewing claims and educating providers on current documentation and billing criteria.

Key Responsibilities

• Conduct thorough examinations of medical records and documentation to assess medical necessity.
• Analyze submitted claims to confirm that billed services are justified medically and coded correctly according to Medicare guidelines, ensuring accurate reimbursement for providers.
• Document clinical findings clearly by preparing written summaries detailing approval, denial, or modification decisions.
• Provide educational outreach to physicians and providers under the Targeted Probe and Educate program to promote compliance.
• Track providers' progress and offer ongoing guidance regarding current billing and documentation standards.
• Maintain compliance with relevant federal/state laws, CMS regulations, and internal company policies.
• Stay informed about updated clinical protocols, medical policy revisions, and best industry practices.

Qualifications

• Associate or Bachelor's degree in Nursing.
• Active Registered Nurse license in good standing for the state where practice is conducted.
• At least one year of clinical experience in healthcare environments such as hospitals, skilled nursing facilities, or home care.
• Strong written and verbal communication skills with the ability to clearly explain complex medical topics.
• Excellent organizational skills and attention to detail to manage multiple concurrent cases.
• Basic familiarity with clinical and medical review procedures.
• Proficiency with computers and multiple online platforms, including Microsoft Outlook, Teams, OneNote, Word, and Excel.
• Preferred: Prior experience with Medicare Administrative Contractors and foundational Medicare knowledge.

Remote Work Requirements

• Reliable high-speed internet with a wired ethernet connection to a computer.
• Internet speed minimums of 10 Mbps downstream and 1 Mbps upstream.

Compensation and Benefits

• Salary range between $68,000 and $72,000 annually, dependent on experience and qualifications.
• Remote working available inapproved states including Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, and Wisconsin.
• Opportunities for performance bonuses and merit increases.
• 401(k) plan with immediate vesting and employer contributions up to 5% of salary.
• Comprehensive health, dental, and telehealth benefits starting from day one.
• Paid time off, leadership and professional development programs.

Employer Information and Culture

WPS is a non-profit health insurer and federal contractor based in Madison, Wisconsin, committed to simplifying healthcare for individuals, families, seniors, and military members. The company fosters a diverse and inclusive culture that values employee engagement, innovation, and adaptability to change. WPS maintains a record of workplace excellence and robust recognition in the industry.

Additional Terms

This role requires adherence to all federal regulations, CMS contract obligations, and company policies related to data security, privacy, and program integrity. All personnel undergo comprehensive background screening including fingerprinting prior to accessing sensitive systems.