Nurse Reviewer

1 month ago


Louisiana, United States Gainwell Technologies LLC Full time
About the Role

We are seeking a skilled Nurse Reviewer to join our team at Gainwell Technologies LLC. As a key member of our team, you will be responsible for performing clinical reviews to determine the appropriateness and reasonableness of medical care. Your expertise will be essential in ensuring that our clients receive high-quality healthcare services.

Key Responsibilities
  • Review and interpret medical records to determine if the documentation supports the need for service, applying critical thinking and decision-making skills to ensure accuracy and quality.
  • Document decisions and rationale to justify review findings or no findings, maintaining production goals and quality standards.
  • Initiate referrals to physician consultants and process their decisions, ensuring that the reason for denial is described in sufficient detail and completed within contractual deadlines.
  • Perform prior authorization, precertification, and retrospective reviews, preparing decision letters as needed to support the utilization review contract.
  • Assist management with training new Nurse Reviewers, providing daily monitoring, mentoring, feedback, and education to ensure a smooth onboarding process.
  • Maintain current knowledge of clinical criteria guidelines and complete required continuing education units (CEUs) to maintain RN licensure.
  • Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
  • Actively cross-train to perform reviews of multiple claim types, providing a flexible workforce to meet client needs.
  • Recommend, test, and implement process improvements, new audit concepts, and technology enhancements to enhance production, quality, and client satisfaction.
Requirements
  • Demonstrated proficiency in computer skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and Internet browsers.
  • Active and unrestricted RN license required.
  • 5+ years of clinical experience in an inpatient hospital setting required.
  • 2+ years of utilization review experience or claims auditing required.
  • Experience using Milliman or InterQual criteria required.
What We Offer

As a remote-based position, you will have the flexibility to work from home and enjoy a better work-life balance. Our company will provide all necessary equipment, including a computer. You will also have the opportunity to grow your career in a company that values work flexibility, learning, and career development.

We believe in creating an inclusive environment for all employees and are committed to diversity, equity, and inclusion. If you are a motivated and detail-oriented individual with a passion for healthcare, we encourage you to apply for this exciting opportunity.


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