Medical Review Nurse

About the Role

The Medical Review Nurse is responsible for reviewing medical reports for TRICARE beneficiaries, determining case closure or need for follow-up care, and issuing authorizations when required. The role involves coordinating with beneficiaries, healthcare providers, and internal teams to ensure accurate, timely, and high‑quality case processing.

Key Responsibilities

• Review and validate incoming medical reports for accuracy and completeness.
• Close cases or perform benefit reviews as needed; issue authorizations or denials.
• Coordinate with network providers for required follow-up care.
• Communicate updates to beneficiaries and clients via email.
• Escalate complex cases or complaints to the Team Leader.
• Maintain confidentiality and accurate case documentation.
• Collaborate with cross-functional teams to support beneficiary care.

Qualifications

• Active Philippines Registered Nurse license (valid for at least 12 months). 
• Bachelor of Science in Nursing.
• At least 2 years clinical experience; broad nursing background preferred.
• Experience in utilization management, case management, or medical report review is a plus.
• Excellent written and spoken English; computer literacy required.
• US RN license desirable but not required.

Key Competencies

• Strong attention to detail and adherence to procedures.
• Effective communication and teamwork.
• Ability to manage time and organize tasks efficiently.
• High standards for quality and customer service.