Nurse Reviewer – Appeals and Hearing

🔥 0 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

💵 $69.4k - $99.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 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

• Coordinate and perform all appeal-related duties • Analyze and respond appropriately to provider appeals • Review documentation to ensure all aspects of appeals are properly and accurately addressed • Review provider appeals and redeterminations using approved clinical and coding guidelines • Document appeal determinations clearly and concisely • Prepare case files and case summaries for hearings • Actively participate in virtual and on-site hearings with the Medical Director • Assist management with training new reviewers through daily monitoring, mentoring, feedback, and education • Maintain current knowledge of clinical criteria and/or coding guidelines • Attend training and scheduled meetings to enhance knowledge of clinical policies, procedures, rules, and regulations • Cross-train to review multiple claim types and support client needs

🎯 Requirements

• Active, unrestricted RN license in the United States • 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 • Working knowledge of the appeals and hearings process • Experience applying clinical review criteria • MCG or InterQual experience preferred • Strong written and verbal communication skills • Ability to develop clear, fact-based appeal rationales • Ability to present case summaries and decisions • Ability to manage multiple priorities in a fast-paced environment • Ability to attend training and scheduled meetings • Ability to successfully complete required CEUs to maintain RN license and/or coding certification

🏖️ Benefits

• Flexible working hours • Work-life balance • Career development • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies • Up to 25% travel for onsite hearing testimony

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