SummaryWe are seeking a talented individual for a Nurse Reviewer (RN) 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 against criteria to assess appropriateness and reasonableness of care; applies critical thinking to ensure documentation supports medical necessity while meeting production and quality goals.
- Documents decisions and rationale clearly to support findings or no findings.
- Determines approvals or refers cases to physician consultants; processes consultant decisions and ensures denial reasons are detailed and completed within deadlines.
- Performs prior authorization, precertification, and retrospective reviews; prepares decision letters as required.
- Assists management in training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education.
- Maintains current knowledge of clinical criteria guidelines and completes CEUs to maintain RN licensure.
- Attends trainings and meetings to stay current on clinical policies, procedures, rules, and regulations.
- Cross-trains to review multiple claim types to maintain workforce flexibility.
- Recommends and helps implement process improvements, new audit concepts, and technology solutions to enhance production, quality, and client satisfaction.
What we're looking for- Proficient in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers.
- Active, unrestricted RN licensure in the U.S. and primary state of residence, plus an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC); verification required during post-offer background check.
- Minimum of 5+ years clinical experience in an inpatient hospital setting required.
- Minimum of 2+ years utilization review or claims auditing experience required.
- Experience with Milliman or InterQual criteria required.
- Ability to work standard business hours with frequent interactions across teams and departments.
- Flexibility to work extended hours when needed to support business demands.
What you should expect in this role- Full-time, permanent salaried (W-2) employee position, not a contract or short-term role.
- Health benefits (medical, dental, vision) and paid time off begin on the first day of employment.
- Standard Monday through Friday work schedule.
- Remote position; employees must be located within the continental U.S. while working.
- Work environment must be private, free of distractions, loud noises, and recording devices.
- May require up to 10% travel depending on business needs.
This position is 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.
