Remote Nurse Reviewer (RN) — Utilization & Review Expert

Gainwell Technologies LLC; Columbus (OH); À distance; USD 78 000 - 88 000; Plein temps

Avantages offerts par ce poste

Medical benefits

401(k) employer match

Flexible vacation policy

Educational assistance

Résumé du poste

Gainwell Technologies LLC is seeking a Nurse Reviewer (RN) to perform clinical reviews ensuring medical necessity based on criteria, policies, and guidelines. You will access proprietary systems, document findings accurately, and support review determinations.

The role is full-time with remote options for US-based employees. Expect to review records, provide policy support, and mentor new Nurse Reviewers while maintaining RN licensure and knowledge of current regulations.

Qualifications

• Proficiency with Windows, Outlook, Excel, Word, PowerPoint and internet browsers.

Responsabilités

• 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 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.

Connaissances

Computer proficiency

Typing

RN license

Outils

Milliman criteria

InterQual criteria

Description du poste

Gainwell Technologies LLC is seeking a Nurse Reviewer (RN) to perform clinical reviews ensuring medical necessity based on criteria, policies, and guidelines. You will access proprietary systems, document findings accurately, and support review determinations.

The role is full-time with remote options for US-based employees. Expect to review records, provide policy support, and mentor new Nurse Reviewers while maintaining RN licensure and knowledge of current regulations.