Nurse Reviewer - Remote Oklahoma

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

Job summary

Gainwell Technologies is seeking a Nurse Reviewer to perform clinical reviews and support healthcare services for vulnerable communities. This home-based role requires an active RN license and offers flexible hours, focusing on improving client health outcomes through innovative solutions.

Benefits

Flexible vacation policies

Educational assistance

Leadership and technical development programs

Qualifications

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

Responsibilities

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

Skills

Clinical experience

Critical thinking

Decision-making

Utilization review

Claims auditing

Education

Active 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. Working at Gainwell carries its rewards, including the chance to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

As a Nurse Reviewer - Remote Oklahoma 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, teaming with people who thrive on finding innovative solutions to healthcare's biggest challenges. Here are the details on 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 Oklahoma.

Your role in our mission

1. Review and interpret medical records, compare against criteria to determine appropriateness and reasonableness of care, applying critical thinking and decision-making skills to support or deny 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, and prepare decision letters in support of the utilization review contract.
5. Assist management in training new Nurse Reviewers, including monitoring, mentoring, feedback, and education.
6. Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN license.
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, providing flexibility to meet client needs.
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

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

What you should expect in this role

• Home-based position exclusively for residents of Oklahoma.
• Company-provided equipment, including a computer.
• Use of video cameras during all interviews and the initial week of orientation.
• Work during normal business hours (9 AM - 6 PM EST), with potential for extended hours and travel based on business needs.
• Minimum internet speed of 24 Mbps download and 8 Mbps upload required; higher speeds preferred for optimal performance.
• To test your internet speed, search "Internet Speed Test" on Google.

LI-NB1

LI-REMOTE

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

The salary range for this position is $49,200 - $70,300 per year, with actual offers depending on geographic region, experience, and other factors. Join Gainwell and turn your passion into a career. We offer flexible vacation policies, educational assistance, and various leadership and technical development programs to enhance your skills.