Medical Reviewer (Registered Nurse) - Remote CA

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

Gainwell Technologies is seeking a Medical Reviewer (Registered Nurse) to support Medical Review Services for California healthcare programs. In this role, you will use your professional nursing experience and clinical judgment to review medical records, healthcare services, claims, and authorization requests.

Your role in our mission

• Review and interpret medical records and clinical documentation to determine medical necessity and appropriateness of healthcare services.

• Provide clinical review support for Treatment Authorization Requests (TARs) and other authorization activities.

• Support medical review activities related to medical policy, claim adjudication, drug utilization review, and other healthcare program requirements as assigned.

• Apply professional nursing principles, clinical judgment, medical policies, and established utilization guidelines when completing reviews.

• Review medical documentation to determine whether requested services, procedures, supplies, and equipment meet applicable coverage and clinical requirements.

• Document review findings, decisions, and supporting clinical rationale accurately and timely.

• Determine approvals within established guidelines or refer cases to physicians or other appropriate clinical professionals when additional review is required.

• Apply knowledge of hospital routines, medical services, medical supplies, and their appropriate clinical uses when conducting reviews.

• Collaborate with physicians, pharmacists, nurses, and other healthcare professionals to support accurate medical review determinations.

• Maintain current knowledge of applicable clinical criteria, medical policies, procedures, and regulatory requirements.

• Meet established quality, accuracy, and productivity standards.

What we're looking for

• Active and unrestricted Registered Nurse (RN) license to practice in the State of California, in good standing.

• Minimum of two (2) years of professional nursing experience.

• Possession of a Master’s Degree in Nursing may substitute for one (1) year of the required professional nursing experience.

• Knowledge of professional nursing principles and techniques, hospital routines, and medical supplies and their uses.

• Training and/or certification in wound and ostomy care preferred.

• Strong clinical judgment and ability to interpret medical records and supporting clinical documentation.

• Experience with medical review, utilization review, medical necessity review, prior authorization, Treatment Authorization Requests (TARs), or claims review preferred.

• Strong written and verbal communication skills.

What you should expect in this role

• Full-time position.

• Remote work environment.

• Monday through Friday work schedule.

• Work primarily from your home office while supporting Medical Review Services for California healthcare programs.

• Spend the majority of your day reviewing medical, clinical, claim, authorization, and/or supporting documentation relevant to your area of expertise.

• Work independently while collaborating with physicians, pharmacists, nurses, other clinical specialists, operations teams, and business partners.

• Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.

• Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status, as applicable.

• Maintain knowledge of applicable medical policies, coverage requirements, clinical standards, and regulatory guidelines.

• Meet established quality, accuracy, productivity, and turnaround-time expectations.

• Receive ongoing training and support related to program requirements, systems, policies, and medical review processes.

This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis.

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The pay range for this position is $70,000 - $100,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

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.