Medical Review Nurse Analyst

Medical Review Nurse Analyst

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.

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 ).
• 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
• Review additional benefits: ()

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…