Clinical Quality Nurse Reviewer, Sr. Specialist

Gainwell Technologies LLC

51d•$64,500 - $92,200•Remote

About The Position

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. SummaryWe are seeking a talented individual for a Clinical Quality Nurse Reviewer, Sr. Specialist who is responsible for performing on-going quality assurance audits of the work performed by clinical staff. This person is responsible for complex quality reviews to determine if decision by review staff matches medical records and approved review methodologies. Responsibilities include reviewing documentation to ensure all aspects of the review audit have been addressed properly and accurately. Performing 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.Your role in our mission Perform QA checks on complex clinical claim reviews Review and analyze claim data and medical records using approved guidelines Document determinations clearly and concisely Report quality findings for trending and performance insights Identify trends and support remediation through training or educational materials Ensure documentation accuracy while meeting quality and production goals Assist with onboarding and mentoring new reviewers Maintain current knowledge of clinical criteria and required CEUs Attend trainings and meetings to stay aligned with policies and regulations Cross-train on multiple claim types to support workload flexibility Serve as SME for proposals and department initiatives Support projects, reporting, and data analysis as needed Consistently meet productivity and quality targets Apply clinical judgement to evaluate medical information and review outcomes

Requirements

Active, unrestricted RN license in the U.S. and in the candidate’s state of primary residence, with a current multistate compact (NLC) license required.
Associate degree required; bachelor’s degree preferred.
5+ years clinical experience in acute setting
3+ years medical record review/auditing experience preferred
Expert level experience applying MCG and/or InterQual criteria
Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of determinations.
Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations.
Ability to multi-task in a fast-paced production environment.

Responsibilities

Perform QA checks on complex clinical claim reviews
Review and analyze claim data and medical records using approved guidelines
Document determinations clearly and concisely
Report quality findings for trending and performance insights
Identify trends and support remediation through training or educational materials
Ensure documentation accuracy while meeting quality and production goals
Assist with onboarding and mentoring new reviewers
Maintain current knowledge of clinical criteria and required CEUs
Attend trainings and meetings to stay aligned with policies and regulations
Cross-train on multiple claim types to support workload flexibility
Serve as SME for proposals and department initiatives
Support projects, reporting, and data analysis as needed
Consistently meet productivity and quality targets
Apply clinical judgement to evaluate medical information and review outcomes