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
The base pay offered for this position may vary within the posted range based on your job-related 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, 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, andmaintainquality 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 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% 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/)

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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WPS Health Blog This position supports services under U.S. Department of Defense (DoD) Defense Health Agency (DHA) contract(s). As such, the role is subject to all applicable federal regulations, DoD contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. 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.