The Medical Review Nurse Analyst is responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines. This role ensures that providers are billing and being paid appropriately for services provided based on Medicare guidelines. The Medical Review Nurse Analyst reviews claims and delivers provider education on current billing and documentation requirements.
Salary Range
68,000-72,000
The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.
Work Location
We are open to remote work 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
How do I know this opportunity is right for me? If you enjoy the following:
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.
Minimum Qualifications
Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).
Active RN license, applicable to state of practice in good standing.
One (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 on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.
Preferred Qualifications
Experience working for a Medicare Administrative Contractor (MAC) preferred.
Basic Medicare knowledge and/or experience preferred.
Remote Work Requirements
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 https://speedtest.net).
Please review Remote Worker FAQs for additional information.
Benefits
Remote work option 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: (https://www.wpshealthsolutions.com/careers/)
SPECIALTIES:
Utilization Review & Management (UR/UM)
