[Hiring] Nurse Reviewer @Gainwell Technologies LLC

Role Description

We are seeking a talented individual for a Nurse Reviewer who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided.

• Apply clinical knowledge to the process of assembling the appeal package for IMR (independent medical review) for physician review.
• Ensure clinically appropriateness of IMR determination letters.
• Perform triage and necessity of IMR expedited appeal requests using federal guidelines and state regulations.
• Perform level of care and utilization review by analyzing medical records and comparing against criteria to determine appropriateness and reasonableness of care.
• 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.
• Assist management with training new reviewers to include daily monitoring, mentoring, feedback and education.
• Maintain current knowledge of clinical criteria guidelines and/or coding guidelines; successfully 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 to meet client needs.

Qualifications

• Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required.
• 5+ years clinical experience in an inpatient hospital setting required.
• 3+ years utilization review experience or claims auditing preferred.
• Experience using InterQual criteria required.
• Ability to multi-task in a fast-paced production environment.

Requirements

• Home based position and you must have a work location within the continental US.
• This position requires that you provide high speed internet connection and a work environment free from distractions.
• Ability to work during normal business hours as this position requires frequent interactions with the team and other departments within the company.
• Ability to work extended hours or on call every other weekend for business needs.
• May be required to travel at least 10% of time based on business needs.

Benefits

• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies to help build your skills and capabilities.