Nurse Reviewer

1 week ago


Columbia, South Carolina, 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 clinical review team, you will play a critical role in ensuring the quality and accuracy of medical records.

Key Responsibilities
  • Review and interpret medical records to determine appropriateness and reasonableness of care, applying critical thinking and decision-making skills to ensure compliance with clinical criteria and guidelines.
  • Document decisions and rationale to justify review findings or no findings, maintaining production goals and quality standards.
  • Initiate referrals to physician consultants and process decisions, ensuring 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 utilization review contracts.
  • Assist management with training new Nurse Reviewers, providing daily monitoring, mentoring, feedback, and education.
  • Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN license.
  • 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 to provide a flexible workforce meeting 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, typing, and Microsoft Office applications.
  • 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 while still being part of a dynamic and collaborative team. Gainwell Technologies LLC offers a competitive salary range of $49,200 - $70,300 per year, as well as a comprehensive benefits package, including health insurance, 401(k) employer match, and educational assistance. We also provide opportunities for career growth and development through our leadership and technical development academies.

We are an equal opportunity employer committed to diversity, equity, and inclusion. We celebrate individual differences and strive to create an inclusive environment for all employees. 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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