SummaryWe are seeking a talented individual for a Clinical Quality Nurse Reviewer, Sr. Specialist who is responsible for performing ongoing quality assurance audits, clinical claims reviews, and clinical/coding audits of medical records and related documentation. This position evaluates whether review determinations align with medical records, approved clinical and coding guidelines, regulatory requirements, and contract-specific review methodologies. Responsibilities include reviewing documentation to ensure all aspects of the review audit have been addressed properly and accurately. Participating in inter-rater reliability assessments and quality assurance auditors for multiple review types including Place of Service, Level of Care, Readmissions, Utilization Management and other specialty reviews.
This position requires strong clinical expertise, advanced auditing experience, and experience applying clinical guidelines such as InterQual and MCG to support accurate quality review outcomes and contribute to continuous improvement across clinical review solutions.
Your role in our mission- Perform Quality Assurance audits using approved clinical guidelines and policies, and document determinations clearly and concisely.
- Analyze and review production and appeal documentation to ensure all aspects of the review are addressed properly, accurately, and in accordance with regulatory requirements while meeting production goals and quality standards.
- Provide detailed documentation of quality review results for trending and reporting.Identify quality trends and work with leadership to develop remediation activities, including educational materials and training sessions to improve the quality of clinical solutions.
- Assist management with training new reviewers, including daily monitoring, mentoring, feedback, and education.Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure.
- Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
- Actively cross-train to perform reviews of multiple claim types and support a flexible workforce that meets client needs.
- Serve as a subject matter expert and contribute to the business proposal process.
- Assist with projects, data analysis, reporting, and feedback as directed by department leadership.
- Demonstrate experience in medical review, chart audits, and quality improvement processes.
- Analyze and evaluate medical information and apply clinical review guidelines and judgment to make clinical determinations.
What we're looking for- Active, unrestricted RN license in the United States and the state of primary residence.
- An active, unrestricted multistate compact RN license as defined by the Nurse Licensure Compact (NLC) is required.Associate degree required; bachelor's degree preferred.
- 5+ years of clinical experience in an acute care setting.
- 5+ years of medical record review/auditing, utilization management, or appeals/hearing experience preferred.
- 3+ years of experience applying national evidence-based guidelines (InterQual and/or MCG).
- Expert-level experience applying MCG and/or InterQual criteria; MCG or InterQual certification preferred.
- Excellent written communication skills, including the ability to write clear, concise, accurate, and fact-based rationales to support determinations.
- Ability to multitask in a fast-paced production environment, adapt quickly to changing priorities, and transition smoothly between client interactions.
What you should expect in this role- Location: Remote (U.S.-based)
- Travel: Up to 10%
- Employment Type: Full-Time
Applications will be accepted through September 30, 2026.
The pay range for this position is $80,000.00 - $95,000.00 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.
