Medical Review Nurse Analyst

Role Overview

The Medical Review Nurse Analyst is tasked with the examination of medical records to verify adherence to regulatory and payer standards. They ensure that providers are billing accurately and receiving appropriate payments per Medicare guidelines and also provide education to providers on current documentation and billing criteria.

Key Responsibilities

• Conduct thorough medical record reviews to assess the medical necessity of services rendered.
• Analyze submitted claims for accuracy and compliance with Medicare coding standards, ensuring providers are properly reimbursed.
• Generate detailed clinical reports outlining approvals, denials, or changes with clear justifications.
• Educate providers through the Targeted Probe and Educate (TPE) program to enhance compliance.
• Track provider performance and offer ongoing education on billing and documentation requirements.
• Maintain compliance with federal/state regulations, CMS guidelines, and company policies.
• Keep updated on clinical guidelines, medical policies, and industry best practices.

Qualifications

• Associate’s Degree in Nursing (ASN) or Bachelor of Science in Nursing (BSN).
• Current Registered Nurse (RN) license valid in the practicing state and in good standing.
• Minimum one year of clinical experience in healthcare environments such as hospitals, home care, or skilled nursing facilities.
• Strong communication skills, both written and verbal, capable of conveying complex medical information clearly.
• Excellent organizational skills and attention to detail for managing multiple cases concurrently.
• Fundamental understanding of clinical and medical review workflows.
• Proficiency with various online technologies including Microsoft Outlook, Teams, OneNote, Word, and Excel.
• Preferred: Experience with Medicare Administrative Contractor (MAC) roles and Medicare knowledge.

Remote Work Requirements

• Reliable wired ethernet connection from router to computer.
• High-speed internet via cable or fiber.
• Minimum internet speeds: 10 Mbps download, 1 Mbps upload.

Benefits and Compensation

• Remote work flexibility in approved states including Georgia, Texas, Illinois, and others.
• Competitive salary range of $68,000 to $72,000 depending on experience and skills.
• Opportunities for performance bonuses and merit increases.
• 401(k) plan with immediate vesting and employer matching contributions.
• Paid time off and health, dental, and telehealth insurance coverage starting from the first day.
• Professional and leadership development programs available.

About WPS

WPS is a veteran-ready, not-for-profit health insurer based in Madison, Wisconsin, providing insurance and Medicare benefit management nationwide. It supports active-duty, retired military personnel, and offers comprehensive health products to individuals and groups, with nearly 80 years of experience facilitating healthcare access.

Culture and Compliance

WPS fosters an inclusive and empowering work culture promoting employee engagement and innovation. As a CMS contractor, this role requires adherence to stringent federal regulations, including background checks and data security measures to protect government resources and sensitive information.