Job description

Role Overview

The Medical Review Nurse Analyst conducts thorough clinical evaluations of medical records to verify adherence to Medicare regulations and payer guidelines. This position ensures accurate provider billing and compensation aligned with Medicare requirements. Additionally, it involves reviewing claims and instructing providers on current billing and documentation standards.

Key Responsibilities

Examine medical records in detail to assess the medical necessity of services rendered.
Evaluate submitted claims ensuring billed services are justified medically and appropriately coded under Medicare standards.
Verify correct reimbursement of Medicare providers when documentation supports the services delivered.
Document clinical findings comprehensively with clear rationales for approvals, denials, or adjustments.
Provide education to providers under the Targeted Probe and Educate (TPE) program framework.
Track assigned providers’ compliance progress and offer guidance on billing and documentation rules.
Ensure all activities comply with federal/state laws, CMS guidelines, and internal policies.
Keep updated with clinical guidelines, medical policy revisions, and industry best practices.

Qualifications and Experience

Associate Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
Active Registered Nurse (RN) license valid for the practicing state.
Minimum of one year clinical healthcare experience in settings such as hospitals, homecare, or skilled nursing facilities.
Strong written and verbal communication skills to convey complex medical data effectively and succinctly.
Exceptional attention to detail and organizational capabilities to handle multiple concurrent cases.
Basic proficiency in clinical/medical review methodologies.
Competency in computer applications including MS Outlook, Teams, OneNote, Word, and Excel.

Preferred Skills

Previous experience with Medicare Administrative Contractor (MAC) operations.
Foundational knowledge of Medicare policies and procedures is desirable.

Work Environment and Requirements

Remote work feasible from specified states including Ohio, Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, South Carolina, Texas, Virginia, Wisconsin.
Mandatory wired ethernet connection from router to computer.
High-speed cable or fiber internet with minimum 10 Mbps download and 1 Mbps upload speeds.

Compensation and Benefits

Salary ranges from $68,000 to $72,000 annually, adjusted according to experience and skills.
Remote work option available.
Potential for performance bonuses and merit-based raises.
401(k) plan offering full match on first 3% and 50% match on next 2% of salary, fully vested immediately.
Generous paid time off.
Health, dental, and telehealth insurance coverage starting from day one.
Opportunities for professional and leadership development.

About WPS

WPS is a nonprofit health insurer and federal government contractor headquartered in Madison, Wisconsin with nearly 80 years of experience. It provides health insurance plans for various groups including individuals, families, seniors, and large businesses. WPS processes Medicare claims and supports military beneficiaries including active-duty and retired personnel. Known for a culture that values employee engagement, inclusivity, and innovation, WPS has earned recognition for its workplace environment. This position involves CMS contracts, requiring adherence to federal regulations and comprehensive background screening.