WPS—A health solutions company
Prior Authorization Nurse Analyst
WPS—A health solutions company, Granite Heights, Wisconsin, United States
Overview
Join to apply for the
Prior Authorization Nurse Analyst
role at
WPS—A health solutions company . The Prior Authorization RN (Registered Nurse) evaluates documentation for medical necessity of medical services and procedures according to Medicare guidelines. This role applies clinical judgment to documentation and renders a provisional coverage decision. The Prior Authorization RN will work alongside Senior Nurse Analysts to ensure that accurate clinical judgement is given based on national and local coverage determinations and direction from CMS to prevent unnecessary procedures and treatments. Salary
Salary Range $66,000 - $68,000 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Work Schedule
This is a full-time, salaried position. Monday through Friday with production hours between 6:00 AM to 6:00 PM CST. There is flexibility on the daily start and end times, as long as 8 hours are worked each day within production hours. Training will be approximately 2 to 3 months and is conducted remotely. Training hours are typically Monday through Friday from 8:00 AM to 4:30 PM CST (these hours could vary slightly). Work Location
We are open to remote work in the following approved states: Arizona, Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin. In This Role You Will
Conduct thorough reviews of submitted clinical documentation to ensure that services are medically necessary in accordance with Medicare policies and guidelines. Verify that all documentation is complete and compliant before services are rendered, ensuring accurate submission for prior authorization. Write clear, concise, and accurate decision letters for healthcare providers that explain the rationale for provisional coverage determinations. Ensure each letter adheres to Medicare guidelines and provides a detailed, well-supported justification for the decision, ensuring transparency and clarity for providers. Review and assess educational materials and national and local coverage determinations, to ensure that documentation requirements are fully understood and met. Ensure that prior authorization requests are submitted with the appropriate supporting information, aligned with Medicare criteria. Maintain consistent communication with Senior Nurse Analysts to seek further education and clarification on complex cases and guidance on policy interpretation. Collaborate with Senior Nurse Analysts and supervisors to resolve provider-related inquiries and enhance the overall workflow of the prior authorization process. Minimum Qualifications
Associate’s Degree in Nursing or Bachelor’s Degree in Nursing (BSN). Active Registered Nurse (RN) license in state of practice or a compact nursing license. 3 or more years of clinical nursing experience such as inpatient or outpatient settings, acute care, home health, hospice, utilization management, case management, or managed care. Solid knowledge and understanding of prior authorization, utilization review, and relevant clinical guidelines. Familiarity with regulatory standards. Strong critical thinking and clinical decision-making skills. Ability to work independently, applying sound nursing judgment, critical reasoning, and creative problem-solving. Strong organizational skills with the ability to meet deadlines, manage competing priorities, and maintain quality standards. Exceptional written and verbal communication skills with the ability to communicate complex medical information clearly and concisely. 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 and hybrid 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/fulltime_benefits.shtml About WPS
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.
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Join to apply for the
Prior Authorization Nurse Analyst
role at
WPS—A health solutions company . The Prior Authorization RN (Registered Nurse) evaluates documentation for medical necessity of medical services and procedures according to Medicare guidelines. This role applies clinical judgment to documentation and renders a provisional coverage decision. The Prior Authorization RN will work alongside Senior Nurse Analysts to ensure that accurate clinical judgement is given based on national and local coverage determinations and direction from CMS to prevent unnecessary procedures and treatments. Salary
Salary Range $66,000 - $68,000 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Work Schedule
This is a full-time, salaried position. Monday through Friday with production hours between 6:00 AM to 6:00 PM CST. There is flexibility on the daily start and end times, as long as 8 hours are worked each day within production hours. Training will be approximately 2 to 3 months and is conducted remotely. Training hours are typically Monday through Friday from 8:00 AM to 4:30 PM CST (these hours could vary slightly). Work Location
We are open to remote work in the following approved states: Arizona, Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin. In This Role You Will
Conduct thorough reviews of submitted clinical documentation to ensure that services are medically necessary in accordance with Medicare policies and guidelines. Verify that all documentation is complete and compliant before services are rendered, ensuring accurate submission for prior authorization. Write clear, concise, and accurate decision letters for healthcare providers that explain the rationale for provisional coverage determinations. Ensure each letter adheres to Medicare guidelines and provides a detailed, well-supported justification for the decision, ensuring transparency and clarity for providers. Review and assess educational materials and national and local coverage determinations, to ensure that documentation requirements are fully understood and met. Ensure that prior authorization requests are submitted with the appropriate supporting information, aligned with Medicare criteria. Maintain consistent communication with Senior Nurse Analysts to seek further education and clarification on complex cases and guidance on policy interpretation. Collaborate with Senior Nurse Analysts and supervisors to resolve provider-related inquiries and enhance the overall workflow of the prior authorization process. Minimum Qualifications
Associate’s Degree in Nursing or Bachelor’s Degree in Nursing (BSN). Active Registered Nurse (RN) license in state of practice or a compact nursing license. 3 or more years of clinical nursing experience such as inpatient or outpatient settings, acute care, home health, hospice, utilization management, case management, or managed care. Solid knowledge and understanding of prior authorization, utilization review, and relevant clinical guidelines. Familiarity with regulatory standards. Strong critical thinking and clinical decision-making skills. Ability to work independently, applying sound nursing judgment, critical reasoning, and creative problem-solving. Strong organizational skills with the ability to meet deadlines, manage competing priorities, and maintain quality standards. Exceptional written and verbal communication skills with the ability to communicate complex medical information clearly and concisely. 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 and hybrid 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/fulltime_benefits.shtml About WPS
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.
#J-18808-Ljbffr