Nurse Reviewer - Remote Idaho

Gainwell Technologies; Idaho; Remote; USD 49,000 - 71,000; Full time

Job summary

Gainwell Technologies is seeking a Nurse Reviewer in Idaho to perform clinical reviews and support healthcare services. This remote role requires an active RN license and offers flexible hours, comprehensive benefits, and opportunities for career growth. Join us to make a difference in healthcare by leveraging your expertise in a supportive environment.

Benefits

Flexible vacation

Educational assistance

Development programs

Qualifications

• 5+ years of clinical experience in an inpatient hospital setting.
• 2+ years of utilization review or claims auditing experience.
• Experience with Milliman or InterQual criteria.

Responsibilities

• Review and interpret medical records against criteria for appropriateness of care.
• Document decisions and rationale for review findings.
• Perform prior authorization and retrospective reviews.

Skills

Clinical experience

Utilization review

Critical thinking

Decision-making

Education

Active and unrestricted RN license

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

As a Nurse Reviewer - Remote Idaho at Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve, especially the community's most vulnerable. Connect your passion with purpose by teaming with people who thrive on finding innovative solutions to healthcare's biggest challenges. Here are the details of this position.

We are seeking a talented individual for a Nurse Reviewer role responsible for performing clinical reviews to determine if medical record documentation supports the need for services based on clinical criteria, coverage policies, and utilization and practice guidelines, as defined by review methodologies specific to the contract for which services are provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy/regulatory support for determinations. This position is only for residents of Idaho.

Your role in our mission

1. Review and interpret medical records, comparing them against criteria to assess the appropriateness and reasonableness of care; apply critical thinking and decision-making skills to determine if documentation supports the need for services while maintaining production goals and quality standards.
2. Document decisions and rationale to justify review findings or no findings.
3. Determine approval or initiate referrals to physician consultants, ensuring reasons for denials are detailed and decisions are completed within contractual deadlines.
4. Perform prior authorization, precertification, and retrospective reviews; prepare decision letters in support of the utilization review contract.
5. Assist management in training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education.
6. Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure.
7. Attend training and scheduled meetings to enhance skills and knowledge of clinical policies, procedures, rules, and regulations.
8. Cross-train to review multiple claim types to meet client needs flexibly.
9. Recommend, test, and implement process improvements, new audit concepts, and technology enhancements to improve production, quality, and client satisfaction.

What we're looking for

1. Active and unrestricted RN license.
2. 5+ years of clinical experience in an inpatient hospital setting.
3. 2+ years of utilization review or claims auditing experience.
4. Experience with Milliman or InterQual criteria.

What you should expect in this role

1. Home-based position for residents of Idaho.
2. Provision of all necessary physical equipment, including a computer.
3. Use of video cameras during interviews and initial orientation week.
4. Work during normal business hours (9 AM - 6 PM EST), with potential for extended hours and travel based on business needs.
5. Minimum broadband internet speed of 24 Mbps download and 8 Mbps upload, with testing instructions provided.

LI-NB1

LI-REMOTE

This position is intended for pipelining; applications are accepted on an ongoing basis.

The pay range for this position is $49,200 - $70,300 per year, with actual offers varying based on location, experience, and other factors. Gainwell offers a comprehensive benefits package, including flexible vacation, educational assistance, and development programs to support your growth.