Medical Review Nurse Analyst

WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready.

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 $66,000 - $70,000 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: Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, Wisconsin

Reviewing submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines. Preparing written clinical summaries and determinations with clear rationale for approvals, denials, or modifications. Educating providers in accordance with the Targeted Probe and Educate (TPE) program. Monitoring the progress of assigned providers and educate on current billing and documentation requirements. Ensuring compliance with federal and state regulations, CMS guidelines, and company policies. Staying current on clinical guidelines, medical policy updates, and industry best practices.