Nurse Reviewer, Registered Nurse

🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $78k - $88k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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 to determine medical necessity and appropriateness of care • Meet quality and productivity standards • Document review decisions and supporting rationale accurately and timely • Determine approvals or refer cases to physician consultants and process consultant decisions • Perform prior authorization, precertification, and retrospective reviews • Prepare decision letters as needed • Assist with training, mentoring, and supporting new Nurse Reviewers • Maintain RN licensure and knowledge of clinical criteria, policies, and regulations • Cross-train on multiple claim types • Recommend process improvements and technology solutions to enhance quality, productivity, and client satisfaction

🎯 Requirements

• Proficiency in computer and typing skills • Proficiency with Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers • Active, unrestricted RN license in the United States and primary state of residence • Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) • Minimum of 5+ years of clinical experience in an inpatient hospital setting • Minimum of 2+ years of utilization review or claims auditing experience • Experience using Milliman or InterQual criteria • Ability to work standard business hours • Ability to collaborate effectively with cross-functional teams and departments • Flexibility to work extended hours as needed to support business demands

🏖️ Benefits

• Flexible hours • Work-life balance • Continuous learning and career development • Day-one eligibility for medical, dental, vision, and paid time off benefits • Educational assistance • Leadership and technical development academies • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • 0–10% travel requirement