Remote Senior Nurse Reviewer - Claims & Utilization

Gainwell Technologies LLC; Columbus (OH); Remote; USD 78,000 - 99,000; Full time

Benefits offered by this job

Flexible work arrangement

Health benefits

Educational assistance

Career development academies

Job summary

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

This role requires clinical review expertise and itemized bill review experience, with potential utilization review responsibilities. Home-based position within the continental US, supporting a flexible, quality-driven team environment.

Qualifications

• Active, Unrestricted RN license within the United States.
• 5+ years clinical experience in an inpatient hospital setting.
• 1+ year itemized bill review experience.
• 3+ years utilization review or claims auditing preferred.
• Experience with CPT, ICD-10, HCPCS coding guidelines.
• Experience using MCG or InterQual criteria.

Responsibilities

• Perform in-depth reviews of medical claims using UB-04 and itemized statements.
• Verify accuracy of itemized charges per client policy and industry standards.
• Conduct level-of-care and utilization reviews and determine appropriateness of care.
• Mentor and train new reviewers and maintain current clinical knowledge.

Skills

RN license

Clinical review

Itemized bill review

Utilization review

Medical coding CPT ICD-10 HCPCS

MCG/InterQual criteria

Tools

MCG criteria

InterQual criteria

Job description

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

This role requires clinical review expertise and itemized bill review experience, with potential utilization review responsibilities. Home-based position within the continental US, supporting a flexible, quality-driven team environment.