Title: Medical Review Nurse Analyst Location: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin Job Description: U.S. Citizenship is required for this position due to Department of Defense restrictions. Our Medical Review Nurse Analyst - Registered Nurse (RN) is responsible for reviewing medical records to determine whether services are payable based on TRICARE policy, reference materials, and evidence-based research. This analyst evaluates clinical documentation across a variety of workloads, including but not limited to authorizations, appeals, and medical review claims. This Medical Review Nurse Analyst collaborates closely with internal teams, providers, and external partners to ensure accurate, timely, and compliant review outcomes. Salary Range $70,000 ~ $85,000 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Work Location 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 reviewing authorization requests by evaluating submitted medical records to determine service eligibility and compliance with TRICARE policy and evidence-based guidelines. - Have analyzed clinical documentation for disputed appeals, ensuring accurate interpretation of medical information and appropriate application of policy and criteria. - Like to review supporting medical documentation for medical review claims, verifying clinical necessity, completeness, and adherence to regulatory requirements. - Can gather, assess, and summarize clinical information needed to support second-level appeal reviews, collaborating with internal stakeholders as required. - Enjoy reviewing escalated or high-risk cases requiring specialized clinical knowledge or interpretation. Minimum Qualifications - U.S. Citizenship is required for this position due to Department of Defense restrictions. - Bachelor’s Degree in Nursing (BSN) or equivalent combination of education and experience.  - Active Registered Nurse (RN) license in state of practice or a compact nursing license.  - 3 or more years of experience in healthcare, health policy, clinical research, or a related field. - Proven experience conducting research, analyzing information, and summarizing findings. - Strong critical thinking, ability to work independently applying sound nursing judgement, creative problem solving, and clinical decision-making skills this includes: - Strong organizational skills with the ability to meet deadlines, manage competing priorities, and maintain quality standards.  - Strong written and verbal communication skills with the ability to communicate complex medical information clearly and concisely.  - Proficiency in Microsoft Office tools (outlook, Word, Excel, One-Note) and shared document environments. Preferred Qualifications - Working knowledge of medical coding (e.g., ICD-10, CPT, HCPCS); Certification in medical coding. - Experience navigating in a multilingual setting. Remote Work Requirements - Wired (ethernet cable) internet connection from your router to your computer. - High speed cable or fiber - 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 Who We Are 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. 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 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.

Provide training and support to Revenue Cycle Analysts, analyze complex financial data to identify trends, lead the preparation of operational reporting metrics, and collaborate with teams to improve revenue cycle outcomes.

• Perform follow-up attempts for both valid and invalid cases in accordance with internal and regulatory requirements, including Targeted Follow-up Questionnaires (TFUQs) when applicable, ensuring that all activities are properly recorded, tracked and documented; • Conduct follow-up telephone contacts with reporters, healthcare professionals, patients or other relevant contacts to obtain additional information and clarify details related to adverse event reports; • Perform required reconciliations according to established internal procedures; • Provide support for general pharmacovigilance activities in compliance with internal procedures, global standards and applicable regulatory requirements.

Title: Senior Revenue Integrity Analyst Location: Ohio United States Job Description: Facility: Work from Home- Ohio Department: Revenue Integrity Services Schedule: Full time Hours: 40 Job Details: The senior revenue integrity analyst is responsible for planning and oversight of the revenue integrity analysts' performance of essential department accountabilities, including reporting to department leadership about goal status. This position will be responsible for all aspects related to revenue integrity, including maintaining work queues, understanding, and applying yearly regulatory changes, maintaining the chargemaster, and preventing revenue leakage. The senior revenue integrity analyst works accounts in assigned Revenue Integrity work queues to facilitate accurate, compliant billing of patient accounts and assists revenue integrity analysts with completion of tasks and work queues. The position will be certified in Epic CDM Management/Revenue Integrity to create, edit, delete and research various CDM requests for all hospital departments for both hospital and professional billing. The senior analyst is responsible for establishing and enforcing the hospitals' pricing, coding, and regulatory changes. The incumbent needs to have knowledge of how billing and the CDM interacts for chargemaster build and will assist in hospital decision making related to chargemaster requests. The position will also provide operational analytical support with regards to reimbursement, charge lag, revenue trends, and other revenue related items. The senior revenue integrity analyst will coordinate and collaborate the above actions with, but not limited to, Health Information Management, Information Systems, Billing, Finance and Operations. Department Specific Job Details: Education - Bachelor's degree in Health Information Management, Finance or related field required - Masters preferred Experience Required - 6-10 years of revenue integrity, analyst, etc. experience in healthcare - Experience with EPIC electronic health record - EPIC CDM/Revenue Integrity (HB and PB) certification within 6 months of employment required - Ability to research CPT and regulatory requirements - Experience with CPT and HCPCS codes and interpreting CPT guidance - Experience in healthcare billing, CMS Medicare and Medicaid reimbursement methodologies - Proficiency in Microsoft Office Tools (Outlook, Excel) Preferred qualifications/skills - Trisus (Craneware) chargemaster experience - Strata experience - Registered Health Information Administrator (RHIA) Certification #Talroo #WayUp