DRG Nurse Reviewer Appeals and Hearings- Remote

Gainwell Technologies LLC; Columbus (OH); Remote; USD 95,000 - 110,000; Full time

Benefits offered by this job

Sign-on bonus

Flexible vacation policy

401(k) employer match

Comprehensive health benefits

Educational assistance

Job summary

Gainwell Technologies LLC seeks a DRG Nurse Reviewer Appeals and Hearings to coordinate all appeal duties, analyze documentation, prepare case files, and participate in hearings.

The role requires an active US RN license, CPC/CCS/CPMA certification, 5+ years clinical or coding experience, and strong written and oral communication to support accurate, timely determinations.

Qualifications

• Active US RN license with primary residence in the United States.
• CPC, CCS or CPMA certification.
• 5+ years clinical experience or 5+ years medical coding experience.
• Strong written and oral communication skills.

Responsibilities

• Reviews provider appeals and redeterminations per clinical and coding guidelines.
• Prepares case files and summaries for hearings and participates in hearings.
• Assists with training and mentoring new reviewers.
• Maintains knowledge of policies and complete CEUs to maintain credentials.
• Collaborates to meet client needs with flexible staffing.

Skills

CPC

CCS

CPMA

RN license (US)

5+ years experience

Education

RN licensure

Job description

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.Sign-on bonuses are available for highly qualified candidates.

Summary

We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings.

Your role in our mission

• Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.
• Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
• Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
• Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
• Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
• Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.

What we're looking for

Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), requiredCertified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required5+ years clinical experience or 5+ years medical record coding experience preferredWorking knowledge of the appeals and hearings processExcellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions.Ability to multi-task in a fast-paced production environment.

What you should expect in this role

Remote (Work from Home) Up to 25% Travel for onsite hearing testimony This position is for pipeline purposes, and we welcome applications on an ongoing basis.

The pay range for this position is $95,000.00 - $110,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Put your passion to work at Gainwell. You’ll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.