SummaryWe are seeking a Nurse Reviewer (RN) who will be responsible for performing clinical reviews to determine whether medical record documentation supports the need for services based on clinical criteria, coverage policies, and utilization and practice guidelines. This role involves accessing proprietary systems to review medical records, accurately documenting findings, and providing policy and regulatory support for review determinations.
Your role in our mission- Reviews and interprets medical records to determine medical necessity and appropriateness of care while meeting quality and productivity standards.
- Documents review decisions and supporting rationale accurately and timely.
- Determines approvals or refers cases to physician consultants and processes consultant decisions.
- Performs prior authorization, precertification, and retrospective reviews; prepares decision letters as needed.
- Assists with training, mentoring, and supporting new Nurse Reviewers.
- Maintains RN licensure and knowledge of clinical criteria, policies, and regulations.
- Cross-trains on multiple claim types to support business needs.
- Recommends process improvements and technology solutions to enhance quality, productivity, and client satisfaction.
What we're looking for- Proficiency in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers.
- Active, unrestricted RN license in the United States and primary state of residence, along with an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
- Minimum of 5+ years of clinical experience in an inpatient hospital setting.
- Minimum of 2+ years of utilization review or claims auditing experience.
- Experience using Milliman or InterQual criteria.
- Ability to work standard business hours, collaborate effectively with cross-functional teams and departments, and maintain the flexibility to work extended hours as needed to support business demands.
What you should expect in this role- Full-time position.
- Day-one eligibility for medical, dental, vision, and paid time off benefits.
- Monday through Friday work schedule.Remote role available to employees residing within the United States.
- Travel requirement: 0-10%.
This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis
The pay range for this position is $78,000.00 - $88,000.00 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.
