Job Description

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

We are seeking a talented individual for a Nurse Reviewer who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination. This position is intended for pipelining. We will accept applications on an ongoing basis.

Your role in our mission

• Reviews and interprets medical records and compares against criteria to determine appropriateness and reasonableness of care; apply critical thinking and decision making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.
• Document decisions and rationale to justify review findings or no findings.
• Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail and completed within contractual deadline.
• Performs prior authorization, precertification, and retrospective reviews and prepares decision letters as needed in support of the utilization review contract
• Assists management with training new Nurse Reviewers to include daily monitoring, mentoring, feedback and education.
• Maintains current knowledge of clinical criteria guidelines and successfully completes required CEUs to maintain RN license
• Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
• Recommends, tests and implements process improvements, new audit concepts, and technology improvements that will enhance production, quality, and client satisfaction

What we’re looking for

• Demonstrated proficiency in computer skills, and typing, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers, etc.
• Active and unrestricted RN license required
• 5+ years clinical experience in an inpatient hospital setting required
• 2+ years utilization review experience or claims auditing required
• Experience using Milliman or InterQual criteria required

What you should expect in this role

• Home based position and you must have a work location within the continental US
• This position requires that you provide high speed internet connection and a work environment free from distractions
• Ability to work during normal business hours as this position requires frequent interactions with the team and other departments within the company
• May be required to work extended hours for special business needs
• May be required to travel at least 10% of time based on business needs
• Our salary range is posted. Please understand that entering all zeros or "negotiable" will result in your application being discarded. Be sure to let us know the exact starting yearly salary you would like on your application.

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#LI-REMOTE

The pay range for this position is $58,200 - $70,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.

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