Nurse Reviewer

2 weeks ago

Bismarck, North Dakota, 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. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy/regulatory support for determination.

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 maintain production goals and quality standards.
  • Document decisions and rationale to justify review findings or no findings.
  • Determine approval or initiate a referral to the physician consultant and process physician consultant decisions, ensuring reason for denial is described in sufficient detail and completed within contractual deadline.
  • Perform prior authorization, precertification, and retrospective reviews, preparing decision letters as needed in support of the utilization review contract.
  • Assist management with training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education.
  • Maintain current knowledge of clinical criteria guidelines and successfully complete required CEUs to maintain RN license.
  • Responsible for attending 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 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 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 worker with Gainwell Technologies LLC, you will have the opportunity to work from home and enjoy a flexible schedule. Our company will provide all necessary equipment, including a computer. You will also have access to training and development opportunities to enhance your skills and knowledge.

We are committed to a diverse, equitable, and inclusive workplace and are proud to be an Equal Opportunity Employer. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.

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