Medical Reviewer, Registered Nurse

🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $70k - $100k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Review and interpret medical records and clinical documentation to determine medical necessity and appropriateness of healthcare services • Provide clinical review support for Treatment Authorization Requests (TARs) and other authorization activities • Support medical review activities related to medical policy, claim adjudication, drug utilization review, and other healthcare program requirements • Apply professional nursing principles, clinical judgment, medical policies, and established utilization guidelines when completing reviews • Review documentation to determine whether requested services, procedures, supplies, and equipment meet coverage and clinical requirements • Document review findings, decisions, and supporting clinical rationale accurately and timely • Determine approvals within established guidelines or refer cases to physicians or other appropriate clinical professionals • Apply knowledge of hospital routines, medical services, medical supplies, and appropriate clinical uses • Collaborate with physicians, pharmacists, nurses, and other healthcare professionals • Maintain current knowledge of clinical criteria, medical policies, procedures, and regulatory requirements • Meet established quality, accuracy, productivity, and turnaround-time standards • Work primarily from a home office supporting Medical Review Services for California healthcare programs • Navigate multiple systems and applications to complete reviews and document findings

🎯 Requirements

• Active and unrestricted Registered Nurse (RN) license to practice in the State of California, in good standing • Minimum of two (2) years of professional nursing experience • Possession of a Master’s Degree in Nursing may substitute for one (1) year of the required professional nursing experience • Knowledge of professional nursing principles and techniques, hospital routines, and medical supplies and their uses • Training and/or certification in wound and ostomy care preferred • Strong clinical judgment and ability to interpret medical records and supporting clinical documentation • Experience with medical review, utilization review, medical necessity review, prior authorization, Treatment Authorization Requests (TARs), or claims review preferred • Strong written and verbal communication skills • Ability to navigate multiple computer systems and applications • Ability to maintain required professional licenses, certifications, and credentials in active, unrestricted, and good-standing status

🏖️ Benefits

• Flexible hours • Work-life balance • Continuous learning and career development • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies • Ongoing training and support