Medical Review Nurse Analyst
WPS—A health solutions company, Virginia, MN, United States
Our
Medical Review Nurse Analyst
is responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines. This analyst ensures that providers are being reimbursed appropriately for services provided based on Medicare guidelines. This
Medical Review Nurse Analyst
reviews claims and delivers provider education on current billing and documentation requirements.
Responsibilities
Perform detailed reviews of medical records and documentation to determine the medical necessity of services.
Review submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines.
Ensure Medicare providers are correctly reimbursed when documentation supports services rendered.
Prepare written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
Educate providers in accordance with the Targeted Probe and Educate (TPE) program.
Monitor the progress of assigned providers and educate on current billing and documentation requirements.
Ensure compliance with federal and state regulations, CMS guidelines, and company policies.
Stay current on clinical guidelines, medical policy updates, and industry best practices.
Minimum Qualifications
Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).
Active RN license, applicable to state of practice in good standing.
1 or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.).
Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
Strong attention to detail and organizational skills to manage multiple cases simultaneously.
Basic knowledge and understanding of medical/clinical review processes.
Solid computer skills with experience working in multiple online systems including MS Outlook, Teams, OneNote, Word, and Excel.
Preferred Qualifications
Experience working for a Medicare Administrative Contractor (MAC).
Familiarity with Medicare guidelines and reimbursement processes.
Experience with medical record review or utilization review.
Remote Work Requirements
Wired (ethernet cable) internet connection from your router to your computer.
High speed cable or fiber internet.
Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net).
Please review Remote Worker FAQs for additional information.
Benefits
Remote work options available
Performance bonus and/or merit increase opportunities
401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
Competitive paid time off
Health insurance, dental insurance, and telehealth services start DAY 1
Professional and Leadership Development Programs
Review additional benefits: https://www.wpshealthsolutions.com/careers/
#J-18808-Ljbffr
Medical Review Nurse Analyst
is responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines. This analyst ensures that providers are being reimbursed appropriately for services provided based on Medicare guidelines. This
Medical Review Nurse Analyst
reviews claims and delivers provider education on current billing and documentation requirements.
Responsibilities
Perform detailed reviews of medical records and documentation to determine the medical necessity of services.
Review submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines.
Ensure Medicare providers are correctly reimbursed when documentation supports services rendered.
Prepare written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
Educate providers in accordance with the Targeted Probe and Educate (TPE) program.
Monitor the progress of assigned providers and educate on current billing and documentation requirements.
Ensure compliance with federal and state regulations, CMS guidelines, and company policies.
Stay current on clinical guidelines, medical policy updates, and industry best practices.
Minimum Qualifications
Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).
Active RN license, applicable to state of practice in good standing.
1 or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.).
Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
Strong attention to detail and organizational skills to manage multiple cases simultaneously.
Basic knowledge and understanding of medical/clinical review processes.
Solid computer skills with experience working in multiple online systems including MS Outlook, Teams, OneNote, Word, and Excel.
Preferred Qualifications
Experience working for a Medicare Administrative Contractor (MAC).
Familiarity with Medicare guidelines and reimbursement processes.
Experience with medical record review or utilization review.
Remote Work Requirements
Wired (ethernet cable) internet connection from your router to your computer.
High speed cable or fiber internet.
Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net).
Please review Remote Worker FAQs for additional information.
Benefits
Remote work options available
Performance bonus and/or merit increase opportunities
401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
Competitive paid time off
Health insurance, dental insurance, and telehealth services start DAY 1
Professional and Leadership Development Programs
Review additional benefits: https://www.wpshealthsolutions.com/careers/
#J-18808-Ljbffr