Prior Authorization Nurse Reviewer

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 talented individual for a Prior Authorization Nurse Reviewer who will be responsible for performing prior authorization reviews of admissions, procedures, services, and supplies based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to review medical information and/or documentation, accurately documenting findings, and providing policy/regulatory support for determination.

Your role in our mission

• Perform prior authorization reviews of admissions, procedures, services, and supplies to determine medical necessity, appropriateness, and reasonableness of care while maintaining production goals and quality standards.
• Complete medical necessity and level of care reviews for requested services using the appropriate clinical criteria and refer to Medical Directors for review depending on case findings.
• Function in a clinical telephone queue working with providers to open a case file, gather clinical information, request additional information, apply the appropriate clinical criteria/guideline, policy, and procedure, and utilize the clinical judgment to render a determination.
• Document decisions and rationale while maintaining pertinent clinical information in various medical management systems
• Assists management with training new Utilization Review Nurses to include daily monitoring, mentoring, feedback, and education.
• Maintains current knowledge of clinical criteria guidelines and successfully completes required CEUs to maintain RN license
• Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-trains to perform multiple review types to provide a flexible workforce to meet client needs.

What we're looking for

• Active and unrestricted nursing license (RN, LPN, or LVN) required
• 5+ years clinical or in facility experience
• 1+ year of utilization review experience
• 1+ year working in a clinical call center environment or the ability to follow business phone etiquette
• Experience in InterQual or Milliman criteria while working under expedited timelines

What you should expect in this role

• Remote (work from home) position and you must be within the continental United States of America
• Core hours for this role are 8:00 AM to 6:00 PM ET – specific hours and schedule will be determined by the supervisor and may be adjusted based on workload requirements
• Gainwell provides all needed equipment for this role (Please be sure to have a physical address on your application that you can receive items.)
• In order to effectively work as a remote worker (work from home) with Gainwell, employees Broadband Internet connections, should have a minimum speed of 24MBS download and 8 MBS upload. Greater speeds will of course provide better performance.
  • To Test your internet download and upload speed:
  • Go to Google.
  • Search for Internet Speed Test or click here.
• Video cameras must be used during all interviews, as well as during the initial week of orientation if hired.
• When applying please attach a resume in English.

This position is intended for pipelining. We will accept applications on an ongoing basis.

The pay range for this position is $57,500.00 - $70,000 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 committed to a diverse, equitable, and inclusive workplace. We are proud to be 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), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.