SummaryWe are seeking a talented individual for a Senior Nurse Reviewer to perform reviews of medical records, healthcare claims, itemized medical bill, and UB-04 forms to ensure accuracy, compliance, and proper billing practices. This position requires clinical review expertise, as well as itemized bill review experience.
Your role in our mission- Perform an in-depth review of medical claims utilizing the UB-04 and detailed itemized statement to ensure the validity of line-item charges.
- Verify accuracy of the itemized charges in accordance with client policy and industry standards.
- Perform level of care and utilization review by analyzing medical records and comparing 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.
- Assists management with training new reviewers to include 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.
- 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.
What we're looking for- Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
- 5+ years clinical experience in an inpatient hospital setting required
- 1+ year itemized bill review experience required
- 3+ years utilization review experience or claims auditing preferred
- Experience with CPT, ICD-10, and HCPCS coding guidelines
- Experience using MCG or InterQual criteria preferred
- Ability to multi-task in a fast-paced production environment.
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
Will accept application until October 23, 2026.
The pay range for this position is $78,000.00 - $99,200.00 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.
