Medical Review Nurse Analyst

Medical Review Nurse Analyst

Responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines, ensuring providers are reimbursed appropriately based on Medicare guidelines, and reviewing claims to deliver provider education on current billing and documentation requirements.

$68,000 - $70,000

Remote work is open in the following approved states:
Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin.

The following qualities and experience make a candidate a good fit for this role:

• Perform detailed reviews of medical records and documentation to determine the medical necessity of services.
• Review submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines.
• Ensure Medicare providers are correctly reimbursed when documentation supports services rendered.
• Prepare written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
• Educate providers in accordance with the Targeted Probe and Educate (TPE) program.
• Monitor the progress of assigned providers and educate on current billing and documentation requirements.
• Ensure compliance with federal and state regulations, CMS guidelines, and company policies.
• Stay current on clinical guidelines, medical policy updates, and industry best practices.

• Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).
• Active RN license, applicable to state of practice in good standing.
• 1 or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.).
• Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
• Strong attention to detail and organizational skills to manage multiple cases simultaneously.
• Basic knowledge and understanding of medical/clinical review processes.
• Solid computer skills with experience working in multiple online systems including MS Outlook, Teams, One Note, Word, and Excel.

• Experience working for a Medicare Administrative Contractor (MAC).
• Familiarity with Medicare guidelines and reimbursement processes.
• Experience with medical record review or utilization review.

• Wired (ethernet cable) internet connection from your router to your computer.
• High speed cable or fiber internet.
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at ).
• Please review Remote Worker FAQs for additional information.

• Remote work options available.
• Performance bonus and/or merit increase opportunities.
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately).
• Competitive paid time off.
• Health insurance, dental insurance, and telehealth services start DAY 1.
• Professional and Leadership Development Programs.
• Review additional benefits:

This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to accessing information systems and/or sensitive data.