Nurse Reviewer (Registered Nurse) - Remote

Gainwell Technologies LLC; Ohio; Remote; USD 78,000 - 88,000; Full time

Benefits offered by this job

Medical benefits

Paid time off

401(k) employer match

Job summary

Gainwell Technologies is seeking a Nurse Reviewer (RN) to perform clinical reviews determining medical necessity and documenting findings. You will access proprietary systems, apply criteria, and support review determinations with policy and regulatory knowledge.

The role is full-time, with day-one benefits, and offers a remote option for US-based employees. Travel is minimal, and opportunities for training and career development are provided.

Qualifications

• Proficiency with Windows, Outlook, Excel, Word, PowerPoint and browsers.
• Active, unrestricted RN license in the United States and primary state of residence.
• 5+ years of clinical inpatient hospital experience.
• 2+ years in utilization review or claims auditing.

Responsibilities

• Reviews and interprets medical records to determine medical necessity and appropriateness of care.
• Documents review decisions and supporting rationale accurately.
• Determines approvals or refers cases to physician consultants.
• Performs prior authorization, precertification, and retrospective reviews.
• Assists with training, mentoring, and supporting new Nurse Reviewers.
• Maintains RN licensure and knowledge of clinical criteria, policies, and regulations.
• Cross-trains on multiple claim types to support business needs.

Skills

Computer skills

RN license

Education

RN license (US)

Tools

Milliman

InterQual

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. Summary

We are seeking a Nurse Reviewer (RN) who will be responsible for performing clinical reviews to determine whether medical record documentation supports the need for services based on clinical criteria, coverage policies, and utilization and practice guidelines. This role involves accessing proprietary systems to review medical records, accurately documenting findings, and providing policy and regulatory support for review determinations.

Your role in our mission

• Reviews and interprets medical records to determine medical necessity and appropriateness of care while meeting quality and productivity standards.
• Documents review decisions and supporting rationale accurately and timely.
• Determines approvals or refers cases to physician consultants and processes consultant decisions.
• Performs prior authorization, precertification, and retrospective reviews; prepares decision letters as needed.
• Assists with training, mentoring, and supporting new Nurse Reviewers.
• Maintains RN licensure and knowledge of clinical criteria, policies, and regulations.
• Cross-trains on multiple claim types to support business needs.
• Recommends process improvements and technology solutions to enhance quality, productivity, and client satisfaction.

What we're looking for

• Proficiency in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers.
• Active, unrestricted RN license in the United States and primary state of residence, along with an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
• Minimum of 5+ years of clinical experience in an inpatient hospital setting.
• Minimum of 2+ years of utilization review or claims auditing experience.
• Experience using Milliman or InterQual criteria.

• Ability to work standard business hours, collaborate effectively with cross-functional teams and departments, and maintain the flexibility to work extended hours as needed to support business demands.

What you should expect in this role

• Full-time position.
• Day-one eligibility for medical, dental, vision, and paid time off benefits.
• Monday through Friday work schedule.Remote role available to employees residing within the United States.
• Travel requirement: 0-10%.

This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis

The pay range for this position is $78,000.00 - $88,000.00 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 the 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. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.