Medical Review Nurse Analyst (Rn) - Remote

Who We Are

WPS Health Solutions is a leading not-for-profit health insurer in Wisconsin. Our services offer health insurance plans for individuals, families, seniors, and group plans for small to large businesses. We process claims and provide customer service 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. In 2021, WPS Health Solutions celebrates 75 years of making health insurance easier for those we serve. Proud to be military and veteran ready.

Our Culture

WPS’ Performance-Based Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive, empowering employee experience, focusing on People, Work, and Conditions. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities. We are guided by our Purpose: Together, making health care easier for the people we serve.

In 2021, 2022, and 2023 WPS Health Solutions was recognized for several awards including:

• Top Workplace national cultural excellence awards for Remote Work and Work-Life Flexibility
• Achievers 50 Most Engaged Workplaces® with the further honor of Achievers “Elite 8” winner in the category of Culture Alignment
• Madison, Wisconsin’s Top Workplaces

Role Snapshot

The Medical Review Nurse Analyst is a work from home position that will review medical documentation submitted to Medicare to ensure providers are billing and being paid appropriately for services provided based on Medicare guidelines. The Medical Review Nurse Analyst will review claims and deliver provider education. Additional details:

• 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 medical documentation reviews
• 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

How do I know this opportunity is right for me? If you:

• Are self-motivated and work with a great degree of independence
• Enjoy educating providers
• Have strong verbal and written communication
• Are technically strong on computers
• 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
• Possess strength in defending your decision-making based on your clinical knowledge

What will I gain from this role?

• Experience working in an environment that serves our Nation’s military, veterans, Guard and Reserves and Medicare beneficiaries
• Learning about our Hyland OnBase tool which is our content management system used for viewing electronic records
• Deepening your understanding of Medicare and how the program works
• Working in a continuous performance feedback environment.
• Collaborating with a team of both clinicians and non-clinicians
• Enjoying a work from home position with daytime hours, no on-call work, no travel, and holidays off

Minimum Qualifications

• Active RN license, applicable to state of practice
• Fiber or cable high speed internet service (satellite internet or hot spots are NOT allowed) that meet our remote work requirements including having a designated work station, a wired (Ethernet) connection to the network, and a minimum of 10Mbps downstream connection with at least 1Mbps upstream (can be checked at https://speedtest.net).
• Bachelor’s Degree in related field or equivalent post high school and/or related work experience

Preferred Qualifications

• 4 or more years of experience in clinical nursing
• Experience with background in Medicare principles and guidelines
• Bachelor’s degree in Nursing

Salary Range

$68,000 to $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 Hours

• Monday through Friday with some flexibility on the start and end time as long as your 8 hour day falls between 6:00 AM CST and 6:00 PM CST
• This is a full-time salaried position.

Work Location

This role is open to remote work for this opportunity 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

Benefits

• Review additional benefits here
• Health, dental insurance, Teladoc starts DAY 1
• Performance bonus and/or merit increase opportunities
• Competitive paid time off
• 401(k) with dollar-per-dollar match up to 6% of salary (100% vested immediately)
• Remote work option available

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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)