Prior Authorization Nurse Analyst

Role Snapshot

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 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.

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 in a new and different way.
• Desire day hours with no on-call work and holidays off.
• Possess strength in defending your decision making based on your clinical knowledge.
• Are technically strong on computers.
• Are self-motivated and work with a great degree of independence.
• Have strong verbal and written communication skills.

What will I gain from this role?

• 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 Nation's military, veterans, Guard and Reserves and Medicare beneficiaries.
• Continuous performance feedback.

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)

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.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.

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This position supports services under Centers for Medicare & 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