Job Description

Nurse Reviewer Associate- Remote Location: Any city, TX, US, 99999 Work Mode: Virtual (Exception only) Summary We are seeking a talented individual for the Nurse Reviewer Associate role. The candidate will perform clinical reviews to determine whether medical record documentation supports the need for a service, based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by the review methodologies specific to the contract. This includes accessing proprietary systems, auditing medical records, documenting findings, and supporting policy and regulatory determinations. Essential Job Functions Review and interpret medical records, compare them against criteria to determine the appropriateness and reasonableness of care. Document decisions and rationale to justify review findings. Determine approvals or initiate referrals to the physician consultant, ensuring denials are explained and completed within contractual deadlines. Perform prior authorization, pre‑certification, and retrospective reviews, and prepare decision letters as needed. Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure. Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross‑train to perform reviews of multiple claim types, providing a flexible workforce to meet client needs. Qualifications Active, unrestricted RN licensure from the United States and in the state of primary residence; an active compact multistate RN license as defined by the Nurse Licensure Compact is required. 3+ years of clinical experience in an inpatient hospital setting. 1+ year of experience in utilization review or claims auditing. Experience using Milliman or InterQual criteria is preferred. What you should expect in this role Home-based position; work location must be within the continental U.S. Provide a high‑speed internet connection and a work environment free from distractions. Full‑time schedule during normal business hours is required. May be required to work extended hours for special business needs. May be required to travel up to 10% of the time based on business needs. Salary range: $70,000.00 - $80,000.00 per year. Base pay may vary based on geographic region, internal equity, and experience. Benefits include a generous flexible vacation policy, a 401(k) employer match, comprehensive health benefits, educational assistance, and leadership and technical development academies. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines "wages" and "wage rates" to include "all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits." #J-18808-Ljbffr

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