Remote RN Reviewer - Utilization & Care Policy

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

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.