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
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
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.
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)