Role Summary: The Medical Review Nurse Analyst will assist in reviewing medical documentation to assure billing providers are billing and being paid appropriately for services provided based on Medicare guidelines.
In this role you will:
Perform review of submitted claims to ensure billed services are medically necessary and correctly coded based on Medicare guidelines
Monitor the progress of assigned providers and educate on current billing and documentation requirements. Through review, ensure Medicare providers are correctly reimbursed when documentation supports services rendered
Educate the provider on documentation requirements for services rendered
Perform post-pay Probe reviews
Perform prepay Targeted Medical Reviews
This role could be a good fit if you:
Are looking to move away from direct patient care and want to use your nursing knowledge in a new and different way
Desire day hours with no on-call work, limited weekend work, and enjoy holidays off
Have strong verbal and written communication
Possess strength in defending your decision making based on your clinical knowledge
Enjoy teaching and training providers
Are technically strong on computers
Are self-motivated and work with a great degree of independence
Have the ability to multitask, set priorities and excel at time management
Enjoy process improvement
You'll benefit from this experience by:
Collaborating with a team of both clinicians and non-clinicians
Understanding Medicare and how the program works
Serving Medicare and educating providers within the WPS jurisdictions
Staying connected with providers
Learning about our Hyland OnBase tool which is our content management system used for viewing electronic records
You need to have:
Associate's degree in Nursing
Active RN license, applicable to state of practice
Four (4) years or more of experience in clinical nursing
We also prefer:
Bachelor's degree in Nursing and/or related field
Experience with background in Medicare principles and guidelines
Your team: This team is comprised of clinical and operational staff
Compensation and Benefits
Eligible for annual Performance Bonus Program
401(k) with dollar-per-dollar match up to 6% of salary
Competitive paid time off
Health and dental insurance start DAY 1
Vision insurance
Flexible spending, dependent care, and health savings accounts
Short- and long-term disability, group life insurance
Dress for your day
Innovative professional and cognitive development programs
Who We Are
WPS Health Solutions is an innovator in health insurance and a worldwide leader in claims administration, serving millions of beneficiaries in the United States and abroad.
Founded in 1946, WPS offers health insurance plans for individuals, families, and seniors, and group plans for small and large businesses. We are a world-class claims processor and program administrator for the government's Medicare program. And we manage benefits for millions of active-duty and retired military personnel and their families.
Our purpose is to make healthcare easier for those we serve. Click Here
Our values - Customer Focused, Individual Responsibility, Mutual Respect, and Driven & Passionate - are the core of who we are and how we conduct business every day.
WPS Health Insurance
WPS Health Insurance offers high-quality health insurance plans for individuals and families, Medicare supplement plans for seniors, and group health plans for businesses of every size.
WPS Military and Veterans Health administers claims and provides customer service and related activities for the U.S. Department of Defense and the U.S. Department of Veterans Affairs and their beneficiaries.
WPS Government Health Administrators manages Medicare Part A and Part B benefits for more than 7 million beneficiaries. As one of the largest contractors for the Centers for Medicare & Medicare Services, we've served Medicare beneficiaries and their health care providers since 1966.
WPS Health Plan offers Health Maintenance Organization and Point-of-Service plans to the group and individual markets in eastern and north-central Wisconsin, plus third-party administrator services.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)