Remote Nurse Reviewer - Utilization & IMR Specialist

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

Benefits offered by this job

Flexible vacation policy

401(k) matching

Health benefits

Educational assistance

Job summary

Gainwell Technologies is seeking a Nurse Reviewer to perform clinical reviews to determine if documentation supports the need for the service according to criteria and policies. This role emphasizes accuracy, compliance, and timely decisions within contract-specific review methodologies.

The position is home-based across the continental US, with flexible hours and opportunities for ongoing CEU development to maintain RN licensure, plus benefits including health coverage and education support.

Qualifications

• Active, unrestricted RN license in the US with a primary home residency.
• 5+ years of clinical experience in an inpatient hospital setting.
• 3+ years utilization review or claims auditing preferred.
• Experience using InterQual criteria required.
• Ability to multitask in a fast-paced production environment.

Responsibilities

• Assemble the appeal package for IMR for physician review.
• Ensure clinical appropriateness of IMR determination letters.
• Triage and determine necessity of expedited IMR appeals.
• Perform utilization review by analyzing records against criteria.
• Apply critical thinking to justify need for service while meeting production goals.
• Assist in training new reviewers with mentoring and feedback.
• Maintain current knowledge of clinical criteria and CEUs to keep RN license.
• Attend trainings and cross-train to review multiple claim types.

Skills

RN license US

Multitasking

Fast-paced environment

Tools

InterQual criteria

Job description

Gainwell Technologies is seeking a Nurse Reviewer to perform clinical reviews to determine if documentation supports the need for the service according to criteria and policies. This role emphasizes accuracy, compliance, and timely decisions within contract-specific review methodologies.

The position is home-based across the continental US, with flexible hours and opportunities for ongoing CEU development to maintain RN licensure, plus benefits including health coverage and education support.