Nurse Reviewer
4 weeks ago
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.
- 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.
As a remote worker with Gainwell Technologies LLC, you will enjoy a flexible work environment, comprehensive health benefits, and educational assistance. Our company values work-life balance, continuous learning, and career development, providing opportunities for growth and advancement.
We are an equal opportunity employer, 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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