Nurse Reviewer - Remote (Idaho Residents Only)

About the position

As a Nurse Reviewer - Remote (Idaho Residents Only) at Gainwell, you will play a crucial role in enhancing healthcare services by utilizing your clinical expertise to perform comprehensive reviews of medical records. Your primary responsibility will be to assess whether the documentation supports the necessity of services based on established clinical criteria, coverage policies, and utilization guidelines specific to the contracts in place. This position is designed for individuals who are passionate about improving the health and well-being of vulnerable populations through innovative solutions in healthcare. In this role, you will engage in critical thinking and decision-making processes to evaluate the appropriateness and reasonableness of care provided. You will document your findings meticulously, ensuring that all decisions are justified and aligned with quality standards. Additionally, you will be responsible for determining approvals or initiating referrals to physician consultants, processing their decisions, and ensuring that all actions are completed within contractual deadlines. Your responsibilities will also include performing prior authorization, precertification, and retrospective reviews, as well as preparing decision letters to support the utilization review contract. You will assist in training new Nurse Reviewers, providing mentorship and feedback to enhance their skills. Staying current with clinical criteria guidelines and completing required continuing education units (CEUs) to maintain your RN license will be essential. This position offers the flexibility of remote work, but it is exclusively available to residents of Idaho. You will be provided with all necessary equipment, including a computer, to facilitate your work from home. The role requires you to work during standard business hours, with the possibility of extended hours based on business needs. You may also need to travel up to 10% of the time, depending on the requirements of the job.

Responsibilities
? Review and interpret medical records against established criteria to determine the appropriateness of care.
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? Apply critical thinking and decision-making skills to assess if medical documentation supports the need for services while meeting production goals and quality standards.
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? Document decisions and rationale to justify review findings or lack thereof.
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? Determine approval or initiate referrals to physician consultants, ensuring detailed descriptions of denials are provided within contractual deadlines.
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? Perform prior authorization, precertification, and retrospective reviews, preparing decision letters as necessary.
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? Assist management in training new Nurse Reviewers, including daily monitoring, mentoring, and providing feedback and education.
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? Maintain current knowledge of clinical criteria guidelines and complete required CEUs to uphold RN license.
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? Attend training and scheduled meetings to enhance skills and knowledge of clinical policies, procedures, rules, and regulations.
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? Cross-train to perform reviews of multiple claim types to provide a flexible workforce.
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? Recommend, test, and implement process improvements and new audit concepts to enhance production, quality, and client satisfaction.

Requirements
? Active and unrestricted RN license required.
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? 5+ years of clinical experience in an inpatient hospital setting required.
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? 2+ years of utilization review experience or claims auditing required.
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? Experience using Milliman or InterQual criteria required.
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? Demonstrated proficiency in computer skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and Internet browsers.

Nice-to-haves

Benefits
? Flexible vacation policy
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? 401(k) employer match
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? Comprehensive health benefits
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? Educational assistance
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? Leadership and technical development academies

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