Clinical Quality Nurse Reviewer, Sr. Specialist

Gainwell Technologies LLC

25d•$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• Conduct quality assurance checks on complex clinical claim reviews and ensure accuracy of determinations.• Analyze claim data and medical records using approved clinical guidelines; document findings clearly.• Provide detailed quality review results for reporting and trend analysis; help identify quality issues and support remediation efforts, including developing training materials.• Ensure all aspects of the clinical review are fully addressed while meeting production and quality standards.• Support training of new reviewers through monitoring, mentoring, and feedback.• Maintain up-to-date knowledge of clinical guidelines and complete required CEUs to keep RN license active.• Participate in training sessions and meetings to strengthen understanding of clinical policies and procedures.• Cross-train to review multiple claim types to support business needs.• Serve as a subject matter expert and assist with proposals, projects, reporting, and data analysis.• Consistently meet performance expectations and demonstrate strong experience in medical review, chart audits, and quality improvement.What we're looking for

Requirements

Active, unrestricted RN licensure from the United States and in the state of primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), 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

Conduct quality assurance checks on complex clinical claim reviews and ensure accuracy of determinations.
Analyze claim data and medical records using approved clinical guidelines; document findings clearly.
Provide detailed quality review results for reporting and trend analysis; help identify quality issues and support remediation efforts, including developing training materials.
Ensure all aspects of the clinical review are fully addressed while meeting production and quality standards.
Support training of new reviewers through monitoring, mentoring, and feedback.
Maintain up-to-date knowledge of clinical guidelines and complete required CEUs to keep RN license active.
Participate in training sessions and meetings to strengthen understanding of clinical policies and procedures.
Cross-train to review multiple claim types to support business needs.
Serve as a subject matter expert and assist with proposals, projects, reporting, and data analysis.
Consistently meet performance expectations and demonstrate strong experience in medical review, chart audits, and quality improvement.