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medicare advantage rn review analyst Jobs in Michigan

medicare advantage rn review analyst

nurse

medical review nurse analyst

WPS—A health solutions company

<div>
 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.
 
 
 
 Salary Range
 
 
 
 
 $68,000 - $70,000
 
 
 
 
 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.
 
 
 
 
 Remote 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:
 
 
 
 <ul>
 <li>
 Can perform detailed reviews of medical records and documentation to determine the medical necessity of services.
 </li>
 <li>
 Would enjoy reviewing submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines.
 </li>
 <li>
 Want to ensure Medicare providers are correctly reimbursed when documentation supports services rendered.
 </li>
 <li>
 Have prepared written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
 </li>
 <li>
 Would like to educate providers in accordance with the Targeted Probe and Educate (TPE) program.
 </li>
 <li>
 Can monitor the progress of assigned providers and educate on current billing and documentation requirements.
 </li>
 <li>
 Want to ensure compliance with federal and state regulations, CMS guidelines, and company policies.
 </li>
 <li>
 Enjoy staying current on clinical guidelines, medical policy updates, and industry best practices.
 
 
 </li>
 </ul>
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Associate&rsquo;s (ASN) or Bachelor&rsquo;s Degree in Nursing (BSN).
 </li>
 <li>
 Active RN license, applicable to state of practice in good standing.
 </li>
 <li>
 1 or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.).
 </li>
 <li>
 Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
 </li>
 <li>
 Strong attention to detail and organizational skills to manage multiple cases simultaneously.
 </li>
 <li>
 Basic knowledge and understanding of medical/clinical review processes.
 </li>
 <li>
 Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Experience working for a Medicare Administrative Contractor (MAC).
 </li>
 <li>
 Familiarity with Medicare guidelines and reimbursement processes.
 </li>
 <li>
 Experience with medical record review or utilization review.
 
 
 </li>
 </ul>
 
 Remote Work Requirements
 
 
 
 <ul>
 <li>
 Wired (ethernet cable) internet connection from your router to your computer
 </li>
 <li>
 High speed cable or fiber internet
 </li>
 <li>
 Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)
 </li>
 <li>
 Please review Remote Worker FAQs for additional information
 
 
 </li>
 </ul>
 
 Benefits
 
 
 
 <ul>
 <li>
 Remote work options available
 </li>
 <li>
 Performance bonus and/or merit increase opportunities
 </li>
 <li>
 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)
 </li>
 <li>
 Competitive paid time off
 </li>
 <li>
 Health insurance, dental insurance, and telehealth services start DAY 1
 </li>
 <li>
 Professional and Leadership Development Programs
 </li>
 <li>
 Review additional benefits: (https://www.wpshealthsolutions.com/careers/)
 
 
 </li>
 </ul>
 
 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&rsquo; 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&mdash;both current and future&mdash;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.
 
 
 We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.
 
 
 
 Sign up for
 
 
 Job Alerts
 
 
 
 
 FOLLOW US!
 
 
 
 
 Instagram
 
 
 
 
 LinkedIn
 
 
 
 
 Facebook
 
 
 
 
 WPS Health Blog
 
 
 
 This position supports services under Centers for Medicare &amp; Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services
</div>

Medical Review Nurse Analyst

Strategic Staffing Solutions

<div>
 
 
 
 Medicare Advantage RN Review Analyst
 
 
 
 
 
 Location:
 
 Detroit, MI
 
 (Remote however must be local to Michigan)
 
 
 
 
 Duration:
 
 12+ Months with opportunity for FTE
 
 
 
 Role Type:
 
 W2 Contract role
 
 
 
 Max Pay Rate:
 
 $36/HR
 
 
 
 Schedule:
 
 Monday - Friday 9-5
 
 
 
 
 
 
 SUMMARY
 
 
 
 Responsible for the approval or rejection of claims and/or benefit interpretation. May be required to enter or reference data via PC and/or Clinical Review Team terminal.
 
 
 
 
 
 
 REQUIREMENTS
 
 
 <ul>
 <li>
 Registered Nurse with current Michigan Registered Nurse License.
 </li>
 <li>
 Associate degree or nursing diploma required, bachelor&rsquo;s degree preferred.
 </li>
 <li>
 Two (2) years RN patient care experience.
 </li>
 <li>
 Triage, case management and/or rehabilitation experience preferred.
 </li>
 <li>
 Medicare Advantage Part B experience a plus.
 </li>
 <li>
 Expertise in the use of medical terminology.
 </li>
 <li>
 Finely honed critical thinking skills are a must.
 </li>
 <li>
 Knowledge of CPT/HCPCS coding and Medicare regulations desirable.
 </li>
 </ul>
 
 
 
 
 
 CERTIFICATES, LICENSES, REGISTRATIONS
 
 
 <ul>
 <li>
 Current unrestricted state of Michigan registered nurse license required.
 </li>
 </ul>
</div>

Medicare Advantage RN Review Analyst

DataAnnotation

<div>
 We are looking for a Nurse to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 
 Physicians &amp; Advanced Practice Clinicians
 
 
 
 In this role you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include:
 
 
 Physicians of all specialties (e.g., Internists, Cardiologists, Oncologists), Physician Assistants, Nurse Practitioners, Certified Nurse-Midwives, Certified Registered Nurse Anesthetists, Clinical Nurse Specialists, Registered Nurses.
 
 
 
 Therapists
 
 
 
 Physical Therapists, Occupational Therapists, Speech-Language Pathologists, Respiratory Therapists, Athletic Trainers, Massage/Recreational Therapists.
 
 
 
 Diagnostic &amp; Laboratory Professionals
 
 
 
 Radiologic Technologists, Sonographers, MRI &amp; Nuclear Medicine Technologists, Medical Laboratory Scientists, Phlebotomists, Histology &amp; Genetics Technicians.
 
 
 
 Public Health &amp; Specialized Roles
 
 
 
 Dietitians/Nutritionists, Genetic Counselors, Epidemiologists, Public Health Nurses.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 This is a full-time or part-time REMOTE position
 </li>
 <li>
 You&rsquo;ll be able to choose which projects you want to work on
 </li>
 <li>
 You can work on your own schedule
 </li>
 <li>
 Projects are paid hourly starting at $50-$60 USD per hour, with bonuses on high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Give AI chatbots diverse and complex healthcare related problems and evaluate their outputs
 </li>
 <li>
 Evaluate the quality produced by AI models for correctness and performance
 </li>
 <li>
 Ensure the medical accuracy of model performance
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in progress medical degree
 
 
 </li>
 </ul>
 Notes: Payment is made via PayPal. We will never ask for any money from you. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contract position.
 
 
 #medicine
</div>

Nurse

<div>
 We are looking for a Nurse Practitioner to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 
 Physicians &amp; Advanced Practice Clinicians
 
 
 
 In this role you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include:
 
 
 Physicians of all specialties (e.g., Internists, Cardiologists, Oncologists), Physician Assistants, Nurse Practitioners, Certified Nurse-Midwives, Certified Registered Nurse Anesthetists, Clinical Nurse Specialists, Registered Nurses.
 
 
 
 Therapists
 
 
 
 Physical Therapists, Occupational Therapists, Speech-Language Pathologists, Respiratory Therapists, Athletic Trainers, Massage/Recreational Therapists.
 
 
 
 Diagnostic &amp; Laboratory Professionals
 
 
 
 Radiologic Technologists, Sonographers, MRI &amp; Nuclear Medicine Technologists, Medical Laboratory Scientists, Phlebotomists, Histology &amp; Genetics Technicians.
 
 
 
 Public Health &amp; Specialized Roles
 
 
 
 Dietitians/Nutritionists, Genetic Counselors, Epidemiologists, Public Health Nurses.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 This is a full-time or part-time REMOTE position
 </li>
 <li>
 You&rsquo;ll be able to choose which projects you want to work on
 </li>
 <li>
 You can work on your own schedule
 </li>
 <li>
 Projects are paid hourly starting at $50-$60 USD per hour, with bonuses on high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Give AI chatbots diverse and complex healthcare related problems and evaluate their outputs
 </li>
 <li>
 Evaluate the quality produced by AI models for correctness and performance
 </li>
 <li>
 Ensure the medical accuracy of model performance
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in progress medical degree
 
 
 </li>
 </ul>
 Notes: Payment is made via PayPal. We will never ask for any money from you. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contract position.
 
 
 #medicine
</div>

Nurse Practitioner

<div>
 We are looking for a Pharmacy Technician to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 
 Physicians &amp; Advanced Practice Clinicians
 
 
 
 In this role you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include:
 
 
 Physicians of all specialties (e.g., Internists, Cardiologists, Oncologists), Physician Assistants, Nurse Practitioners, Certified Nurse-Midwives, Certified Registered Nurse Anesthetists, Clinical Nurse Specialists, Registered Nurses.
 
 
 
 Therapists
 
 
 
 Physical Therapists, Occupational Therapists, Speech-Language Pathologists, Respiratory Therapists, Athletic Trainers, Massage/Recreational Therapists.
 
 
 
 Diagnostic &amp; Laboratory Professionals
 
 
 
 Radiologic Technologists, Sonographers, MRI &amp; Nuclear Medicine Technologists, Medical Laboratory Scientists, Phlebotomists, Histology &amp; Genetics Technicians.
 
 
 
 Public Health &amp; Specialized Roles
 
 
 
 Dietitians/Nutritionists, Genetic Counselors, Epidemiologists, Public Health Nurses.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 This is a full-time or part-time REMOTE position
 </li>
 <li>
 You&rsquo;ll be able to choose which projects you want to work on
 </li>
 <li>
 You can work on your own schedule
 </li>
 <li>
 Projects are paid hourly starting at $50-$60 USD per hour, with bonuses on high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Give AI chatbots diverse and complex healthcare related problems and evaluate their outputs
 </li>
 <li>
 Evaluate the quality produced by AI models for correctness and performance
 </li>
 <li>
 Ensure the medical accuracy of model performance
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in progress medical degree
 
 
 </li>
 </ul>
 Notes: Payment is made via PayPal. We will never ask for any money from you. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contract position.
 
 
 #medicine
</div>

Pharmacy Technician

<div>
 We are looking for a
 
 Clinical Appeals Nurse
 
 to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 In this role, you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include Clinical Documentation &amp; HIM, Medication Management (PharmD), Laboratory Medicine and Pathology Services (MLS, MD), Quality Improvement &amp; Patient Safety, Regulatory Compliance, Accreditation &amp; Medical Staff, Care Coordination &amp; Case Management, Population Health &amp; Value-Based Care, and Managed Care &amp; Utilization Management.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 Full-time or part-time remote position
 </li>
 <li>
 Choose which projects you want to work on
 </li>
 <li>
 Flexible schedule
 </li>
 <li>
 Projects are paid hourly starting at $50+ per hour
 </li>
 <li>
 Bonuses available for high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Provide AI chatbots with diverse and complex healthcare-related problems
 </li>
 <li>
 Evaluate AI outputs for logic, accuracy, and performance
 </li>
 <li>
 Ensure the medical accuracy and overall quality of model responses
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in-progress medical or healthcare-related degree
 
 
 </li>
 </ul>
 
 Notes:
 
 Payment is made via PayPal. We will never ask you for any money. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contractor position.
 
 
 
 #medicine
 
</div>

Clinical Appeals Nurse

LanceSoft, Inc.

<div>
 
 
 Job Responsibilities:
 
 
 <ul>
 <li>
 The Care Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person centric care management program to a diverse health plan population with a variety of health and social needs.
 </li>
 <li>
 They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages and the online messaging platform.
 </li>
 <li>
 The Care Manager RN uses the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the members health across the care continuum.
 </li>
 <li>
 They work in partnership with the member, providers of care and community resources to develop and implement the plan of care and achieve stated goals.
 </li>
 </ul>
 
 
 
 
 
 Education and Experience:
 
 
 <ul>
 <li>
 Nursing Diploma or Associates degree in nursing required.
 </li>
 <li>
 Bachelor&rsquo;s degree in nursing strongly preferred.
 </li>
 <li>
 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting required.
 </li>
 <li>
 1 year of case management experience in a managed care setting strongly preferred.
 </li>
 <li>
 Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred.
 </li>
 <li>
 Current, active, and unrestricted Michigan Registered Nurse license required
 </li>
 <li>
 Certification in Case Management (CCM) required or to be obtained within 18 months of hire
 </li>
 <li>
 Certification in Chronic Care Professional (CCP) preferred
 </li>
 </ul>
</div>

Case Management Nurse

Explore 11+ Medical review nurse analyst in Michigan this May. Find roles across top companies and apply now to boost your career.