Medical Review Nurse Analyst
WPS Health Solutions · Centralia, WA
Job description
Medical Review Nurse Analyst The Medical Review Nurse Analyst is responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines. This role ensures that providers are billing and being paid appropriately for services provided basedon Medicare guidelines. The Medical Review Nurse Analyst reviews claims and delivers provider education on current billing and documentation requirements. Salary Range 68,000-72,000 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin. How do I know this opportunity is right for me? If you enjoy the following: • 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. • One (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 on-line systems including MS Outlook, Teams, OneNote, Word, and Excel. Preferred Qualifications: • Experience working for a Medicare Administrative Contractor (MAC) preferred. • Basic Medicare knowledge and/or experience preferred. 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 ). • Please review Remote Worker FAQs for additional information. Benefits: • Remote work option 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: ( ) WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, 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 has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready. WPS' culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique 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.
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Introduction The State of Connecticut, Department of Transportation (CTDOT), is now accepting applications for a Customer Experience Trainee (Connecticut Careers Trainee - Engineering And Related) position with a target class of Transportation Planner 1 within the Customer Experience unit in the Bureau of Public Transportation in Newington, CT. WHAT WE CAN OFFER YOU • Visit our new State Employee Benefits Overview page! • Professional growth and development opportunities • A healthy work/life balanceto all employees • Join an award-winning agency! CTDOT has been recently awarded the Employer of the Year award by the Connecticut Society of Civil Engineers (CSCE) and named the Women's Transportation Seminar (WTS) CT Employer of the Year for 2024! POSITION HIGHLIGHTS • Monday - Friday • Full-time (40 hours per week) • First shift • Location: Newington, CT • This position is eligible to apply for telework after successful completion of the working test period, and thereafter, in accordance with the Telework Policy. Employees in their initial working test period must work on site in the office. THE TEAM AND ROLE The Customer Experience unit was established to ensure that transit customers and their experiences are influencing and supporting innovation and decision-making with the state's public transportation services. The unit oversees CTDOT's Customer Experience Action Plan, statewide fare transformation initiatives, FTA Title VI Service and Fare Equity Analyses, public outreach and communication with transit customers and stakeholders, and other customer-facing projects and programs. This role is designed for candidates eager to learn, grow, and contribute to high-impact projects in a collaborative environment. This posting may be used to fill future positions in the Customer Experience unit. As a Connecticut Careers Trainee, you will receive on-the-job training and mentorship to develop skills in transportation planning. Working closely with experienced transit planners, you will help interpret bus and rail customer feedback data to develop actionable insights. APPOINTMENT The length of the development program is determined by the experience and training requirements of the designated class and the prior experience of the incumbent. At the completion of the development program incumbents must meet the experience and training requirements of the designated class. The program cannot be less than one (1) year and cannot exceed three (3) calendar years in accordance with C.G.S. 5-234. Incumbents in this class will be eligible for reclassification to the designated class without competitive examination upon successful completion of the development program and satisfactory service. All appointments to this class shall be under terms of a development program and in accordance with a time schedule approved by the Commissioner of Administrative Services. All development programs must be approved by the Department of Administrative Services prior to appointment to this class. Eligibility for promotion to the target classification of Transportation Planner 1 is earned upon successful completion of your training program: • Candidates with a bachelor's degree may be eligible to serve a 2-year development program. • Candidates with a master's degree in a closely related field may be eligible to serve a 1-year development program. • Candidates with three (3) years of professional experience in transportation engineering or transportation, urban, regional or environmental planning may be eligible to serve a 3-year development program. SALARY NOTE First year of training: Bachelor's degree and/or qualifying experience: FS 15 Step 1 ($58,130/year) Master's degree: FS 15 Step 2 ($60,222/year) Second year of training: General rate: FS 15 Step 5 ($66,512/year) The salary for an employee who completes any of the above minimum requirements after initial appointment to the Connecticut Careers Trainee job class will be adjusted commensurate with the schedule above and effective the pay period following the date the master's degree has been conferred or the pay period following the date the appropriate number of credits as indicated above have been earned. For current state employees, compensation will be in accordance with guidelines for computing salary adjustments set forth by the Department of Administrative Services, Determining Salary Upon Change in Class manual. ABOUT US As one of Connecticut's largest State agencies, the Connecticut Department of Transportation (CTDOT) employs roughly 3,300 individuals across five bureaus. CTDOT is guided by its mission to improve lives through transportation. Our infrastructure and transit systems are essential to the safety and mobility of Connecticut residents, and our work strengthens both economic and community development. CTDOT is committed to fostering a workforce that reflects the communities it serves, and individuals with broad-ranging backgrounds and life experiences are encouraged to apply. Learn more about our mission, vision, and values! Selection Plan FOR ASSISTANCE IN APPLYING: Check out our Applicant Tips on How to Apply! Need more resources? Visit our Applicant Toolkit for additional support throughout the recruitment process. BEFORE YOU APPLY: • Meet Minimum Qualifications: Ensure you meet the Minimum Qualifications listed on the job opening by the job closing date. You must specify your qualifications on your application. The minimum experience and training requirements listed must be met by the close date on the job opening, unless otherwise specified. • Educational Credits: List your earned credits and degrees from accredited institutions accurately on your application. To receive educational credits towards qualification, the institution must be accredited. If the institution of higher learning is located outside of the U.S., you are responsible for providing documentation from a recognized USA accrediting service which specializes in determining foreign education equivalencies to the contact listed below by the closing date listed on the job posting. • Resume Policy: Per Public Act 21-69, resumes are not accepted during the initial application process. As the recruitment process progresses, candidates may be required to submit additional documentation to support their qualification(s) for this position. This documentation may include: a cover letter, resume, transcripts, diplomas, performance reviews, attendance records, supervisory references, licensure, etc., at the request and discretion of the hiring agency. • Preferred Shift/Location: Select all location(s) and shift(s) you are willing to work on your application. Failure to do so may result in not being considered for vacancies in that specific location or shift. • Timely Submission: All application materials must be received by the job posting deadline. You will be unable to make revisions once you officially submit your application to the State. Late submissions are rarely accepted, with exceptions only for documented events that incapacitate individuals during the entire duration of the job posting. Request exceptions by emailing DAS.SHRM@ct.gov (Opens in a New Window). • Salary Calculations: For current state employees, salary calculations are not necessarily comparable from one of the three branches of state government (i.e., Executive, Legislative, Judicial) to the other. • Note: The only way to apply to this posting is via the 'Apply' or 'Apply Online' buttons on the official State of Connecticut Online Employment Center job posting. AFTER YOU APPLY: • Some email providers may experience delays or issues delivering messages. To avoid missing important updates-such as referral questionnaires or interview scheduling links-please check your Personal Status Board regularly. • For added convenience, you can also enable text (SMS) notifications. To do this, log in to your Personal Status Board and select "Update My Contact Information." • Referral Questions: This posting may require completion of additional Referral Questions (RQs), which must be completed by the questionnaire's expiration date. If requested, RQs can be accessed via an email sent to you after the job close date or by visiting your JobAps Personal Status Board (Certification Questionnaires section). • Prepare For An Interview: Interviews are limited to those whose experience and training are most aligned with the role. To prepare, review this helpful Interview Preparation Guide to make the best impression! • Stay connected! Log in daily to your JobAps Personal Status Board to track your status and check email (including spam/junk folders) for updates and tasks. • The immediate vacancy is listed above, however, applications to this recruitment may be used for future vacancies in this job class. • Note: This position will be filled in accordance with contractual language, reemployment, SEBAC, transfer, promotion and merit employment rules. Candidates who are offered and accept a position with the State of Connecticut are bound by the State Code of Ethics for Public Officials and State employees, available at www.ct.gov/ethics. • This employer may participate in E-Verify and will provide the federal government with your Form I-9 information to confirm work authorization. QUESTIONS? WE'RE HERE TO HELP: Due to high volume, we are unable to confirm receipt or provide status updates directly. For recruitment updates, please check your Personal Status Board and review our Frequently Asked Questions. If you have additional questions about the recruitment process, reach out to Frank DeCusati at frank.decusati@ct.gov (Opens in a New Window). Join the State of Connecticut and take your next career step with confidence! PURPOSE OF JOB CLASS (NATURE OF WORK) In a state agency this class is accountable for mastering the skills necessary to satisfactorily complete the training program for a professional position. EXAMPLES OF DUTIES • Contributes to the development of the Bureau of Public Transportation Customer Comment Clearinghouse - an initiative to automate, centralize, and analyze all transit customer feedback data submitted to CTDOT and transit agencies throughout the state; • Assists with responding to transit customer and stakeholder inquiries and tracks and maintains a communications log to ensure responses are provided in a timely manner; • Helps develop and maintain reports, visualizations, and dashboards to communicate insights to staff, leadership, and stakeholders; • Contributes to the development of metrics and key performance indicators aligned with the Bureau of Public Transportation mission and strategic goals; • Assists with the implementation, evaluation, and future updates to CTDOT's Customer Experience Action Plan; • Assists with public engagement activities with transit customers and stakeholders; • Supports other unit initiatives, including statewide fare transformation, FTA Title VI Service and Fare Equity analysis, and customer-facing transit technology projects, as needed; • Performs related duties as required. KNOWLEDGE, SKILL AND ABILITY • Oral and written communication skills; • Ability to • acquire knowledge and skills required for the target classification; • understand, evaluate and solve problems by exercising judgement and logic; • read, interpret and understand written material; • perform basic arithmetical computations; • interpret charts, graphs and tables; • learn and reason; • establish and maintain cooperative relations with superiors, associates and general public; • utilize computer software. MINIMUM QUALIFICATIONS Candidates must be able to meet the experience and training requirements of the designated job class at the completion of the development program. PREFERRED QUALIFICATIONS • A Bachelor's or Master's degree in Public Administration, Public Policy, Urban or Regional Planning, Data Science, Computer Science, Data Analytics, Business Analytics, Statistics, Applied Mathematics, Marketing, Communications, or a closely related field • Experience or training with Microsoft Office (Word, Excel, PowerPoint, and Outlook) or similar software through coursework, work experience, or internship experience • Experience or training in data collection, databases, data analysis, and data visualization through coursework, work experience, or internship experience • Experience or training communicating in writing and verbally with members of the public through coursework, work experience, or internship experience • Experience or training working in a high-volume, deadline-driven environment while managing multiple priorities simultaneously through coursework, work experience, or internship experience • Experience utilizing public transportation services, or experience or training in public transportation planning and operations through coursework, work experience, or internship experience Conclusion AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER The State of Connecticut is an equal opportunity/affirmative action employer and strongly encourages the applications of women, minorities, and persons with disabilities. ACKNOWLEDGEMENT As defined by Sec. 5-196 of the Connecticut General Statutes, a job class is a position or group of positions that share general characteristics and are categorized under a single title for administrative purposes. As such, a job class is not meant to be all-inclusive of every task and/or responsibility.