Gainwell Technologies

Nurse Reviewer Appeals and Hearings- Remote

Gainwell Technologies • $75K — $95K *
Wrangell, AK 99929In-Person
Healthcare
5 - 7 years of experience
1 week ago
Job Overview by Ladders

Qualifications

  • Active RN license in the U.S. with home residency or compact multistate license
  • 5+ years of clinical experience or medical record coding experience
  • 3+ years of utilization review or claims auditing experience
  • Working knowledge of appeals and hearings processes
  • Experience with MCG or InterQual criteria preferred
  • Excellent written communication skills for rationales
  • Strong verbal skills for presenting case summaries

Responsibilities

  • Review provider appeals using clinical and coding guidelines, documenting determinations clearly
  • Analyze appeal documentation to ensure accuracy while meeting production and quality standards
  • Prepare case files and summaries for hearings, and participate actively in hearings
  • Assist management in training new reviewers, providing mentorship and feedback
  • Maintain updated knowledge of clinical and coding guidelines through CEUs
  • Attend training and meetings to enhance skills and knowledge of policies and regulations
  • Cross-train to handle multiple types of claims for workforce flexibility

Benefits

  • Remote work opportunity within the U.S.
  • Flexible vacation policy
  • 401(k) employer match
  • Comprehensive health benefits
  • Educational assistance programs
  • Access to leadership and technical development academies
Full Job Description
Summary

We are seeking a talented individual for a Nurse Reviewer Appeals and Hearings role to coordinate and perform all appeal-related duties, including analyzing and responding appropriately to provider appeals; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; preparing case files and case summaries for hearings; and participating in virtual and on-site hearings.

Your role in our mission

  • Reviews provider appeals and redeterminations using approved clinical and coding guidelines, and documents appeal determinations clearly and concisely.
  • Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
  • Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
  • Assists management with training new reviewers, including daily monitoring, mentoring, feedback, and education.
  • Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
  • 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 that meets client needs.


What we're looking for

  • Active, unrestricted RN license in the United States and primary home residency; active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
  • 5+ years of clinical experience or 5+ years of medical record coding experience required.
  • 3+ years of utilization review experience or claims auditing required.
  • Working knowledge of the appeals and hearings process.
  • Experience using MCG or InterQual criteria preferred.
  • Excellent written communication skills, including the ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
  • Excellent oral communication skills, with particular emphasis on verbally presenting case summaries and decisions.
  • Ability to multi-task in a fast-paced production environment.


What you should expect in this role

  • Remote within the U.S.
  • Up to 25% travel


Applications for this posting will be accepted until July 30, 2026.

The pay range for this position is ((salaryMin)) - ((salaryMid)) 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.

About Gainwell Technologies

Gainwell Technologies offerings including Medicaid Management Information Systems (MMIS), fiscal agent services, program integrity, care management, immunization registry, and eligibility services. With over 50 years of proven experience, Gainwell carries forward a reputation for technological innovation, service excellence, and unparalleled industry expertise in offering clients scalable and flexible health and human services solutions for their most complex challenges.

Gainwell Technologies Careers

There has never been a more opportune time to join Gainwell Technologies, a leader in providing cutting-edge technology solutions. As a hub of innovation and diversity, Gainwell Technologies offers a plethora of job opportunities aimed at enhancing the digital landscape.

Work You’ll Do

Join Gainwell Technologies' esteemed team to assist some of the most prominent organizations in mastering their technological advancements and digital transformations. At Gainwell Technologies, the focus is on leveraging a unique blend of technology, industry expertise, and digital innovation to lead the market. Professionals at Gainwell Technologies are positioned uniquely at the crossroads of technology and consulting, driving leadership and growth in various sectors through transformative solutions.

Gainwell Technologies Professional Growth and Opportunities

The team is dedicated to building a leading-edge environment that fosters professional growth and innovation. Gainwell Technologies is not just about addressing the current needs of the market but also about foreseeing and shaping the future of technology.

Innovative Work

At Gainwell Technologies, employees engage in groundbreaking work at the intersection of technology and practical application. The company is home to a large group of dedicated professionals who are committed to delivering robust solutions on trusted platforms.

Career Advancement

Embark on a career journey with Gainwell Technologies where the sky is the limit. The company supports ambitious professionals with comprehensive training, development programs, and diverse certification opportunities designed to future-proof careers in the technology sector.

Explore Job Opportunities and Culture

Gainwell Technologies is committed to creating a workplace culture that promotes diversity and inclusion, where every team member’s contribution is valued. Explore various job opportunities, from internships to full-time positions, and become part of a team that values innovation and leadership.

The Gainwell Technologies Commitment to Diversity and Professional Development

Gainwell Technologies recognizes the importance of diversity training and professional development in creating a thriving workplace. The company is dedicated to providing employees with the resources they need to succeed in their careers and contribute to the industry effectively.

Stay Connected with Gainwell Technologies Careers

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Discover open positions that align with your skills and interests. Gainwell Technologies is on the lookout for passionate, curious, and creative professionals who are driven to find solutions and excel in their careers. SEARCH GAINWELL TECHNOLOGIES JOBS

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Learn more about Gainwell Technologies
Size
10,001 employees
Industry
Information Technology
* Ladders Estimates

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