Medical Reviewer, Appeals and Hearings Specialist

3 weeks ago


Lexington, Kentucky, United States Gainwell Technologies Full time
Job Description for Nurse Reviewer, Appeals and Hearings

We are seeking a dedicated and skilled Nurse Reviewer, Appeals and Hearings to join our team at Gainwell Technologies. In this role, you will be responsible for reviewing provider appeals and redeterminations using approved clinical and coding guidelines, documenting determinations clearly and concisely, and preparing case files and case summaries for hearings.

Key Responsibilities:
  • Reviews provider appeals and redeterminations using approved clinical and coding guidelines.
  • Documents appeal determinations clearly and concisely.
  • Prepares case files and case summaries for hearings.
  • Participates in virtual and on-site hearings.
  • Trains new reviewers in daily monitoring, mentoring, feedback, and education.
  • Maintains current knowledge of clinical criteria guidelines and/or coding guidelines.
Requirements:
  • Active, unrestricted RN licensure from the United States and in the state of primary home residency.
  • Compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
  • Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) preferred.
  • 5+ years clinical experience or 5+ years medical record coding experience preferred.
  • Working knowledge of the appeals and hearings process.
  • Excellent written communication skills, including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
What We Offer:
  • Full-time permanent regular salaried (W-2) employee position.
  • Upward career advancement is possible and encouraged.
  • Health (medical, dental, vision) and paid time off benefits start on day 1 of employment.
  • Company match 401K and other benefits available within months of starting.
  • Computer and other company-provided items.

This is a remote position with a requirement for broadband internet connection with a minimum speed of 24MBS download and 8MBS upload.



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