Nurse Reviewer (Registered Nurse) - Remote (Any city, TX, US, 99999)

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 We are seeking a Nurse Reviewer (RN) who will be responsible for performing clinical reviews to determine whether medical record documentation supports the need for services based on clinical criteria, coverage policies, and utilization and practice guidelines. This role involves accessing proprietary systems to review medical records, accurately documenting findings, and providing policy and regulatory support for review determinations. Your role in our mission Reviews and interprets medical records to determine medical necessity and appropriateness of care while meeting quality and productivity standards. Documents review decisions and supporting rationale accurately and timely. Determines approvals or refers cases to physician consultants and processes consultant decisions. Performs prior authorization, precertification, and retrospective reviews; prepares decision letters as needed. Assists with training, mentoring, and supporting new Nurse Reviewers. Maintains RN licensure and knowledge of clinical criteria, policies, and regulations. Cross-trains on multiple claim types to support business needs. Recommends process improvements and technology solutions to enhance quality, productivity, and client satisfaction. What we're looking for Proficiency in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers. Active, unrestricted RN license in the Unite