[Hiring] Nurse Reviewer Appeals and Hearing @Gainwell Technologies LLC

Role Description

We are seeking a talented individual for a Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including:

• Analyzing and responding appropriately to appeals from providers.
• Reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately.
• Preparing case files and case summaries for hearings.
• Participating in virtual and on-site hearings.

Your role in our mission includes:

• Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.
• Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
• Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
• Assists management with training new reviewers to include daily monitoring, mentoring, feedback, and education.
• Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
• Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.

Qualifications

• Active, unrestricted RN license in the United States and, if applicable, an active multistate RN license under the Nurse Licensure Compact (NLC).
• 5+ years of clinical experience or medical record coding experience.
• 3+ years of utilization review or claims auditing experience, with working knowledge of the appeals and hearings process.
• Experience applying clinical review criteria, with MCG or InterQual experience preferred.
• Strong written and verbal communication skills, including the ability to develop clear, fact-based appeal rationales, present case summaries and decisions, and manage multiple priorities in a fast-paced environment.

Requirements

• Remote (Work from Home).
• Up to 25% Travel for onsite hearing testimony.
• The deadline to submit applications for this posting is December 31, 2026.
• The pay range for this position is 69,400.00 - 99,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Benefits

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