Utilization Review Nurse

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $64.5k - $82k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🦅 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 evaluate prior authorization requests to determine medical necessity, appropriateness, and cost-effectiveness of services • Support access to quality care while ensuring compliance with program requirements and clinical guidelines • Serve as a clinical resource for providers, customers, and internal teams by resolving healthcare-related questions and concerns • Collaborate with providers, members, and internal stakeholders to facilitate timely and appropriate healthcare decisions • Interpret and apply complex clinical, regulatory, and procedural guidelines • Support utilization review and case management activities through clinical assessment and decision-making • Assist in developing and improving healthcare policies, provider communications, and program initiatives • Contribute to healthcare cost containment efforts while ensuring appropriate, medically necessary care • Work independently while partnering with cross-functional teams to achieve program goals

🎯 Requirements

• Bachelor's degree or equivalent combination of education and experience • Active, unrestricted RN or LPN license in the United States • Strong oral and written communication skills • Strong analytical, organizational, and time management skills • Ability to read, understand, and interpret complex regulatory and procedural documents • Proficiency with PC-based systems and applications • Ability to work independently with minimal supervision • Two or more years of Medicaid experience or other healthcare experience • Previous experience supporting Utilization Review, Prior Authorization, Case Management, or Managed Care programs

🏖️ Benefits

• Flexible hours • Work-life balance • Continuous learning and career development • 100% remote work environment • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies