Nurse Reviewer - IMR (Remote)

Gainwell Technologies LLC•Any city, OH

2d•$78,000 - $88,000•Remote

About The Position

Gainwell Technologies is seeking a Nurse Reviewer to perform clinical reviews that determine whether medical record documentation supports the need for services under clinical criteria, coverage policies, and utilization and practice guidelines specific to each contract. The role applies clinical expertise to independent medical review (IMR) appeals and supports accurate, timely review determinations. This is a home-based position requiring a work location within the continental United States, a high-speed internet connection, and a distraction-free work environment. The schedule follows normal business hours and may include extended hours or on-call work every other weekend based on business needs. Travel may be required at least 10% of the time. Applications will be accepted until October 30, 2026.

Requirements

Active, unrestricted RN license in the United States and in the primary home residency, or an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
At least 5 years of clinical experience in an inpatient hospital setting.
Experience using InterQual criteria.
Ability to multitask in a fast-paced production environment.
Provide a high-speed internet connection and a work environment free from distractions.
Ability to work during normal business hours and to work extended hours or be on call every other weekend when business needs require.
Ability to travel at least 10% of the time if required by business needs.

Nice To Haves

At least 3 years of utilization review experience or claims auditing.

Responsibilities

Apply clinical knowledge to assemble IMR appeal packages for physician review.
Ensure the clinical appropriateness of IMR determination letters.
Triage IMR expedited appeal requests and assess medical necessity using federal guidelines and state regulations.
Conduct level-of-care and utilization reviews by analyzing medical records and comparing them with criteria to assess the appropriateness and reasonableness of care.
Use critical thinking and decision-making skills to determine whether medical record documentation supports the need for services while meeting production goals and quality standards.
Assist management in 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 units to maintain an RN license.
Attend training and scheduled meetings to enhance knowledge of clinical policies, procedures, rules, and regulations.
Cross-train to review multiple claim types to support workforce flexibility and client needs.