Remote RN: Senior Claims & Utilization Reviewer

Gainwell Technologies LLC; United States; Remote; USD 78,000 - 99,000; Full time

Benefits offered by this job

Flexible vacation policy

401(k) employer match

Comprehensive health benefits

Educational assistance

Job summary

Gainwell Technologies is seeking a Senior Nurse Reviewer to perform reviews of medical records, healthcare claims, itemized bills, and UB-04 forms to ensure accuracy and proper billing practices.

The role requires an active RN license, inpatient clinical experience, and itemized bill review expertise. It is a home-based position within the continental US with occasional travel and extended hours as needed.

Qualifications

• Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
• 5+ years clinical experience in an inpatient hospital setting required
• 1+ year itemized bill review experience required
• 3+ years utilization review experience or claims auditing preferred
• Experience with CPT, ICD-10, and HCPCS coding guidelines
• Experience using MCG or InterQual criteria preferred
• Ability to multi-task in a fast-paced production environment.

Responsibilities

• Perform an in-depth review of medical claims utilizing the UB-04 and detailed itemized statement to ensure the validity of line-item charges.
• Verify accuracy of the itemized charges in accordance with client policy and industry standards.
• Perform level of care and utilization review by analyzing medical records and comparing against criteria to determine appropriateness and reasonableness of care.
• Apply critical thinking and decision making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.
• Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
• Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license.
• Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.

Skills

RN license

Clinical experience

Bill review

Utilization review

CPT/ICD-10/HCPCS

MCG/InterQual

Multi-tasking

Job description

Gainwell Technologies is seeking a Senior Nurse Reviewer to perform reviews of medical records, healthcare claims, itemized bills, and UB-04 forms to ensure accuracy and proper billing practices.

The role requires an active RN license, inpatient clinical experience, and itemized bill review expertise. It is a home-based position within the continental US with occasional travel and extended hours as needed.