Nurse Reviewer Appeals and Hearing

Gainwell Technologies LLC•Any city, OH

5d•$69,400 - $99,200•Remote

About The Position

Gainwell Technologies is seeking a Nurse Reviewer Appeals and Hearings to coordinate and perform appeal-related duties. The role analyzes and responds to provider appeals, reviews documentation for completeness and accuracy, prepares case files and summaries for hearings, and participates in virtual and on-site hearings. The reviewer applies approved clinical and coding guidelines, documents determinations clearly, and meets production goals and quality standards. The position also supports training new reviewers through monitoring, mentoring, feedback, and education; maintains current knowledge of clinical and coding guidelines and required credentials; attends training and meetings; and cross-trains to review multiple claim types. This is a remote work-from-home role with up to 25% travel for on-site hearing testimony.

Requirements

Active, unrestricted RN license in the United States and, if applicable, an active multistate RN license under the Nurse Licensure Compact (NLC).
At least 5 years of clinical experience or medical record coding experience.
At least 3 years of utilization review or claims auditing experience, with working knowledge of the appeals and hearings process.
Strong written and verbal communication skills, including the ability to develop clear, fact-based appeal rationales, present case summaries and decisions, and manage multiple priorities in a fast-paced environment.

Nice To Haves

Experience applying clinical review criteria.
MCG or InterQual experience.

Responsibilities

Review provider appeals and redeterminations using approved clinical and coding guidelines, and document determinations clearly and concisely.
Analyze appeal documentation to ensure all aspects of an appeal have been properly and accurately addressed while meeting production goals and quality standards.
Prepare case files and case summaries for hearings and participate in hearings with the Medical Director.
Assist management with training new reviewers through daily monitoring, mentoring, feedback, and education.
Maintain current knowledge of clinical criteria and/or coding guidelines and complete required continuing education to maintain an RN license and/or coding certification.
Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
Cross-train to review multiple claim types to provide a flexible workforce for client needs.