Nursing Services Reviewer, Specialist

🔥 18 minutes ago

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 10%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.Why this score:

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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

• Perform clinical reviews to determine whether medical record documentation supports the need for services • Review and interpret medical records against clinical criteria, coverage policies, utilization guidelines, and practice guidelines • Access proprietary systems to audit medical records • Document findings, decisions, and rationale accurately • Determine approvals or refer cases to physician consultants • Process consultant decisions and complete detailed denial reasons within deadlines • Perform prior authorization, precertification, and retrospective reviews • Prepare decision letters as required • Assist management with training new Nurse Reviewers through monitoring, mentoring, feedback, and education • Maintain knowledge of clinical criteria guidelines and complete CEUs to maintain RN licensure • Attend trainings and meetings concerning clinical policies, procedures, rules, and regulations • Cross-train to review multiple claim types • Recommend and help implement process improvements, audit concepts, and technology solutions

🎯 Requirements

• Active, unrestricted RN licensure in Massachusetts required • Compact multistate RN license strongly preferred • Minimum of 5+ years clinical experience in an inpatient hospital setting required • Minimum of 2+ years utilization review or claims auditing experience required • Experience with Milliman or InterQual criteria required • Proficient in computer and typing skills • Proficiency with Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers • Ability to work standard business hours with frequent interactions across teams and departments • Flexibility to work extended hours when needed to support business demands • Must reside within the United States and work from the continental U.S. • Must maintain an active Massachusetts RN license • Private, distraction-free work environment without loud noises or recording devices

🏖️ Benefits

• Health benefits (medical, dental, vision) begin on the first day of employment • Paid time off begins on the first day of employment • Full-time, permanent salaried W-2 employee position • Remote work arrangement • Standard Monday through Friday work schedule

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