Medical Review Nurse Analyst (RN), Remote Work at WPS Health Solutions in Jacksonville, Florida

Posted in Other 7 days ago.

Job Description:


Role Summary:

Are you considering a career move away from direct patient care and want to use your nursing knowledge in a new and different way? If you desire a remote nursing position with daytime hours and no on-call work this position may be for you!

The Medical Review Nurse Analyst will review medical documentation for post pay claims submitted to Medicare to ensure providers are billing and being paid appropriately for services provided based on Medicare guidelines, specifically for beneficiaries eligible for both Medicare and Medicaid. The Medical Review Nurse Analyst will review claims and deliver provider education as warranted.

In this role you will:

  • Reach out to and educate providers in accordance with the Targeted Probe and Educate (TPE) program.

  • 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 providers on documentation requirements for services rendered

  • Perform post-pay medical documentation 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 to help patients in a new and different way

  • Have the ability to transform sensitive situations into teachable opportunities for future success

  • Possess strength in defending your decision-making based on your clinical knowledge

  • Enjoy educating providers

  • Are technically strong on computers

  • Are self-motivated and work with a great degree of independence

  • Have strong verbal and written communication

You'll benefit from this experience by:

  • Enjoying a work from home position with daytime hours, no on-call work, limited weekend work, and holidays off

  • Collaborating with a team of both clinicians and non-clinicians

  • Deepening your understanding of Medicare and how the program works

  • Serving Medicare and educating providers within WPS jurisdictions

  • 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 or equivalent

  • 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

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.

Learn more about WPS.

Our Purpose and Values

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.

Military and Veterans Health

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.

Government Health Administrators

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

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.

EPIC Specialty Benefits

EPIC Specialty Benefits provides businesses group insurance products that cover:

  • Life

  • Disability

  • Dental

  • Vision

  • Voluntary benefits

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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)
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