Medical Review Nurse Analyst

WPS Health Solutions New • Madison, WI

4d • Remote

About The Position

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. 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.

Requirements

• 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.
• 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.
• 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.

Nice To Haves

• Working knowledge of medical coding (e.g., ICD-10, CPT, HCPCS); Certification in medical coding.
• Experience navigating in a multilingual setting.

Responsibilities

• Reviewing authorization requests by evaluating submitted medical records to determine service eligibility and compliance with TRICARE policy and evidence-based guidelines.
• Analyzing clinical documentation for disputed appeals, ensuring accurate interpretation of medical information and appropriate application of policy and criteria.
• Reviewing supporting medical documentation for medical review claims, verifying clinical necessity, completeness, and adherence to regulatory requirements.
• Gathering, assessing, and summarizing clinical information needed to support second-level appeal reviews, collaborating with internal stakeholders as required.
• Reviewing escalated or high-risk cases requiring specialized clinical knowledge or interpretation.

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level