Nurse Reviewer (Registered Nurse)

Gainwell TechnologiesHealthcare utilization review

Remote role available to employees residing within the United States.Full-TimeSenior

Salary78,000 - 88,000 USD per year

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Job Details

Experience: Minimum of 5+ years of clinical experience in an inpatient hospital setting; minimum of 2+ years of utilization review or claims auditing experience.
Required Skills: Microsoft Excel

Maintain an active, unrestricted RN license in the United States and primary state of residence.
Maintain an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
Have at least 5 years of clinical experience in an inpatient hospital setting.
Have at least 2 years of utilization review or claims auditing experience.
Have experience using Milliman or InterQual criteria.
Be proficient with Microsoft Windows, Outlook, Excel, Word, PowerPoint, internet browsers, and typing.
Be able to work standard business hours and extended hours as needed to support business demands.
Collaborate with cross-functional teams and departments.

Review and interpret medical records to determine medical necessity and appropriateness of care against clinical criteria, coverage policies, and utilization and practice guidelines.
Document review decisions and supporting rationale accurately and on time.
Determine approvals or refer cases to physician consultants, then process consultant decisions.
Perform prior authorization, precertification, and retrospective reviews.
Prepare decision letters as needed.
Assist with training, mentoring, and supporting new Nurse Reviewers.
Maintain RN licensure and knowledge of clinical criteria, policies, and regulations.
Cross-train on multiple claim types to support business needs.
Recommend process improvements and technology solutions to enhance quality, productivity, and client satisfaction.

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