Nurse Reviewer (Registered Nurse) - Remote in US - Any city, KY, US, 99999
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.
Summary
We are seeking a talented individual for a Nurse Reviewer who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination. This position is intended for pipelining. We will accept applications on an ongoing basis.
Your role in our mission
- Reviews and interprets medical records and compares 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.
- Document decisions and rationale to justify review findings or no findings.
- Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail and completed within contractual deadline.
- Performs prior authorization, precertification, and retrospective reviews and prepares decision letters as needed in support …
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Regions Countries Benefits/Perks401(k) employer match Career development Comprehensive health benefits Educational Assistance Flexible Vacation Flexible vacation policy Generous, flexible vacation policy Health benefits Leadership and technical development academies Medical Technical development academies Vacation policy Work flexibility Work-life balance
SkillsAudit Claims Auditing Clinical Experience Computer Excel Healthcare Innovation InterQual InterQual criteria Leadership Microsoft Windows Outlook PowerPoint Technology Training Utilization Review Word
Tasks- Attend training and meetings
- Leadership
- Training
5 years
Certifications TimezonesAmerica/Anchorage America/Chicago America/Denver America/Los_Angeles America/New_York Pacific/Honolulu UTC-10 UTC-5 UTC-6 UTC-7 UTC-8 UTC-9