Medical Review Nurse Analyst (RN) – Remote US

About the role

The Medical Review Nurse Analyst (RN) is responsible for evaluating medical records to determine payment eligibility under TRICARE policy. This role involves reviewing authorizations, appeals, and medical review claims while collaborating with internal teams, providers, and external partners to ensure accurate and compliant outcomes.

Key responsibilities

• Review authorization requests and assess clinical documentation for compliance with TRICARE policy and evidence‑based guidelines.
• Analyze disputed appeals, interpreting medical information and applying relevant criteria.
• Validate supporting documentation for medical review claims, confirming clinical necessity and regulatory adherence.
• Gather, assess, and summarize clinical data for second‑level appeal reviews, coordinating with stakeholders as needed.
• Handle escalated or high‑risk cases that require specialized clinical judgment.

Required profile

• U.S. citizenship (Department of Defense restriction).
• Bachelor’s Degree in Nursing (BSN) or equivalent experience.
• Active RN license in the state of practice or a compact license.
• Minimum 3 years of experience in healthcare, health policy, clinical research, or a related field.
• Proven ability to conduct research, analyze information, and summarize findings.
• Strong critical‑thinking, independent decision‑making, and problem‑solving skills.

Required skills

• Microsoft Outlook
• Microsoft Word
• Microsoft Excel
• Microsoft OneNote
• Working knowledge of ICD‑10 coding
• Working knowledge of CPT coding
• Working knowledge of HCPCS coding

What we offer

• Competitive salary range $70,000 – $85,000 per year.
• Remote work option across approved U.S. states.
• Opportunities to collaborate with multidisciplinary teams on complex clinical cases.