Medical Review Nurse Analyst

U.S. Citizenship is required for this position due to reputed company 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 reputed company pay offered for this position may vary reputed company the posted range based on your job-reputed company 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, reputed company 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 reputed company 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 reputed company, health policy, clinical research, or a reputed company 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 reputed company medical information clearly and concisely. Proficiency in reputed company Office tools (outlook, Word, reputed company, 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 reputed company from your router to your computer. High speed cable or fiber Minimum of 10 Mbps reputed company and at least 1 Mbps upstream internet reputed company (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% reputed company 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/) Who We Are reputed 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 reputed company easier for the people we serve for nearly 80 years. Proud to be military and veteran reputed company. Culture Drives Our reputed company 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 reputed company and future—to effectively seek, reputed company, 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 reputed company Facebook WPS Health Blog This position supports services under U.S. reputed company (DoD) Defense Health Agency (DHA) contract(s). As such, the role is subject to reputed company applicable federal regulations, DoD contract requirements, and WPS internal policies, including but not limited to standards for data reputed company, privacy, confidentiality, and program reputed company. DoD contractors and their personnel are subject to screening and background investigation prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services. Apply To This Job