Nurse Reviewer Associate- Remote

Gainwell Technologies LLC

2d•$70,000 - $80,000•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 the Nurse Reviewer, Associate position. In this role, you will perform clinical reviews to determine whether medical record documentation supports the need for a service, based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by the review methodologies specific to the contract. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy and regulatory support for determinations.

Requirements

Active, unrestricted RN licensure from the United States and in your state of primary residence; an active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) is also required.
3+ years of clinical experience in an inpatient hospital setting.
1+ years of experience in utilization review or claims auditing.
Demonstrated proficiency in computer skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, internet browsers, and typing.

Nice To Haves

Experience using Milliman or InterQual criteria is preferred.

Responsibilities

Review and interpret medical records, comparing them against criteria to determine the appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess whether the documentation supports the need for the service while maintaining production goals and quality standards.
Document decisions and rationale to justify review findings or no findings.
Determine approvals or initiate referrals to the physician consultant, processing their decisions while ensuring denials are explained in sufficient detail and completed within contractual deadlines.
Perform prior authorization, precertification, and retrospective reviews, and prepare decision letters as needed in support of the utilization review contract.
Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure.
Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
Actively cross-train to perform reviews of multiple claim types, providing a flexible workforce to meet client needs.