Senior Clinical Quality Nurse Reviewer - Prior Auth/UM

🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $80k - $95k / year

⏰ Full Time

🟠 Senior

🦅 H1B Visa Sponsor

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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 quality assurance audits using approved clinical guidelines and policies • Analyze and review production and appeal documentation for accuracy, completeness, regulatory compliance, production goals, and quality standards • Document quality review results for trending and reporting • Identify quality trends and work with leadership to develop remediation activities, educational materials, and training sessions • Assist management with training new reviewers through monitoring, mentoring, feedback, and education • Maintain current knowledge of clinical criteria guidelines • Attend training and scheduled meetings • Cross-train to perform reviews of multiple claim types • Serve as a subject matter expert and contribute to the business proposal process • Assist with projects, data analysis, reporting, and feedback • Perform medical review, chart audits, and quality improvement processes • Analyze medical information and apply clinical review guidelines and judgment to make clinical determinations • Participate in inter-rater reliability assessments and audits across Place of Service, Level of Care, Readmissions, Utilization Management, and specialty reviews

🎯 Requirements

• Active, unrestricted RN license in the United States and the state of primary residence • Active, unrestricted multistate compact RN license as defined by the Nurse Licensure Compact (NLC) required • Associate degree required; bachelor's degree preferred • 5+ years of clinical experience in an acute care setting • 5+ years of medical record review/auditing, utilization management, or appeals/hearing experience preferred • 3+ years of experience applying national evidence-based guidelines (InterQual and/or MCG) • Expert-level experience applying MCG and/or InterQual criteria • MCG or InterQual certification preferred • Excellent written communication skills, including ability to write clear, concise, accurate, fact-based rationales • Ability to multitask in a fast-paced production environment, adapt to changing priorities, and transition between client interactions • Ability to complete required CEUs to maintain RN licensure

🏖️ 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