[Hiring] Senior Nurse Reviewer @Gainwell Technologies LLC

Role Description

We are seeking a talented individual for a Senior Nurse Reviewer to perform reviews of medical records, healthcare claims, itemized medical bills, and UB-04 forms to ensure accuracy, compliance, and proper billing practices. This position requires clinical review expertise, as well as itemized bill review experience.

• Perform an in-depth review of medical claims utilizing the UB-04 and detailed itemized statement to ensure the validity of line-item charges.
• Verify accuracy of the itemized charges in accordance with client policy and industry standards.
• 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.
• 1+ year itemized bill review experience required.
• 3+ years utilization review experience or claims auditing preferred.
• Experience with CPT, ICD-10, and HCPCS coding guidelines.
• Experience using MCG or InterQual criteria preferred.
• 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.
• May be required to work extended hours for special business needs.
• May be required to travel at least 10% of time based on business needs.

Benefits

• The pay range for this position is $78,000.00 - $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.
• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Variety of leadership and technical development academies to help build your skills and capabilities.