The Prior Authorization Nurse Analyst is a work from home position that will assist in reviewing medical documentation for prior authorization requests submitted.
In this role you will:
Perform review of submitted documentation to assure planned services are medically necessary based on Medicare guidelines.
Provide written explanations for non-affirming prior authorization requests.
Educate the provider on documentation requirements for planned services.
Perform other job-related duties as assigned.
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 holidays off
Possess strength in defending your decision making based on your clinical knowledge
Are technically strong on computers
Are self-motivated and work with a great degree of independence
Have strong verbal and written communication skillsets
You'll benefit from this experience by:
Collaborating with a team of both clinicians and non-clinicians
Deepening your understanding of Medicare and how the program works
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
We also prefer:
Bachelor's degree in Nursing and/or related field
4 or more years of experience in clinical nursing
Experience with background in Medicare principles and guidelines
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
Flexible spending, dependent care, and health savings accounts
Short- and long-term disability, group life insurance
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.
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.
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)