Senior Professional Nurse

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.

Job Duties:

• Conduct objective desk and medical record audits to verify service documentation, determine appropriate administration, and validate coding/billing accuracy.

• Interview providers and health plan members to assess potential fraud, waste, or abuse.

• Collaborate with internal teams (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to collect relevant documentation for investigations.

• Identify potential healthcare fraud, waste, and abuse by analyzing aberrant coding and billing patterns through utilization review.

• Communicate effectively with physicians and healthcare professionals during investigations.

• Prepare accurate and timely reports detailing audit findings for internal and external stakeholders.

• Provide provider education on best practices (e.g., coding) based on national/local guidelines, contractual obligations, and regulatory requirements.

• Identify process improvement opportunities and recommend system enhancements to optimize investigative outcomes and performance.

Job Qualifications:

• Graduate from an accredited School of Nursing.

Required Experience, Knowledge, Skills & Abilities:

• Minimum of five years of clinical nursing experience with broad clinical knowledge.

• At least five years of experience in medical review and coding/billing audits for both professional and facility-based services.

• Strong understanding of medical terminology, CPT, ICD-9/10, HCPCS, and DRG coding requirements.

• Minimum two years of managed care experience.

Required License, Certification & Associations:

• Active, unrestricted RN license in good standing.

• Preferred: Bachelor’s Degree in Nursing.

• Experience with government healthcare programs (Medicare, Medicaid, SCHIP).

• Experience in long-term care preferred.

Job Details:

Location: 100% Remote within the U.S.

The pay range for this position is $64,000.00 - $80,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.