Medical Review Nurse Analyst RN

Description
Who We Are
WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer 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. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran-ready.
Culture Drives Our Success
WPS Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive and empowering employee experience. We recognize the benefits of Diversity, Equity, and Inclusion as an investment in our workforce-both current and future-to effectively seek, leverage, and include diverse perspectives that fuel agility and innovation on high-performing teams. 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 proud of the recognition we have received from local and national organizations regarding our culture and workplace: WPS Newsroom – Awards and Recognition
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:
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 to ensure Medicare providers are
correctly reimbursed when documentation supports services rendered.
Educate providers on documentation requirements for services rendered.
Perform medical documentation reviews.
How do I know this opportunity is right for me? 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.
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.
What will I gain from this role?
Enjoying a work from home position with daytime hours, no on-call work, no travel, and holidays off
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.
Experience working in an environment that serves our Nations military, veterans, Guard and Reserves and Medicare beneficiaries.
Working in a continuous performance feedback environment
Minimum Qualifications :
Associate or Bachelor Degree in Nursing.
Active RN license, applicable to state of practice.
Preferred Qualifications
Bachelors Degree in Nursing.
4 or more years of experience in clinical nursing.
1 or more years of medical claims review experience
Experience with Medicare contracts (MAC experience)
Experience with background in government Medicare principle