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Nurse Reviewer

2 months ago

Jackson, Mississippi, 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 healthcare team, you will be responsible for performing clinical reviews to determine the appropriateness and reasonableness of medical care. This role requires a strong understanding of clinical criteria, coverage policies, and utilization and practice guidelines.

Key Responsibilities
  • Review and interpret medical records to determine if the documentation supports the need for service
  • 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
  • Initiate referrals to physician consultants and process their decisions
  • Perform prior authorization, precertification, and retrospective reviews, and prepare decision letters as needed
  • Assist management with training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education
  • Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure
  • Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations
  • Cross-train to perform reviews of multiple claim types to provide a flexible workforce to meet client needs
  • Recommend, test, and implement process improvements, new audit concepts, and technology improvements 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 licensure 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
  • Home-based position for residents of Mississippi only
  • Gainwell Technologies LLC will provide all necessary physical equipment, including a computer
  • Video cameras must be used during all interviews and the initial week of orientation if hired
  • Ability to work during normal business hours (9 AM - 6 PM EST) with frequent interactions with the team and other departments within the company
  • May be required to work extended hours for special business needs or travel at least 10% of the time based on business needs
  • Internet connection with a minimum speed of 24MBS download and 8MBS upload required

Gainwell Technologies LLC 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, 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.