Clinical Quality Nurse Reviewer, Sr. Specialist- Remote
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 Clinical Quality Nurse Reviewer, Sr. Specialist who is responsible for performing on-going quality assurance audits of the work performed by clinical staff. This person is responsible for complex quality reviews to determine if decision by review staff matches medical records and approved review methodologies. Responsibilities include reviewing documentation to ensure all aspects of the review audit have been addressed properly and accurately. Performing inter-rater reliability assessments and quality assurance auditors for multiple review types including Place of Service, Level of Care, Readmissions, Utilization Management and other specialty reviews. Your role in our mission
- Conduct QA checks on complex clinical claim reviews.
- Analyze claims and medical records using approved guidelines.
- Document review findings clearly and accurately.
- Identify quality trends and support improvements through training and education.
- Ensure reviews meet accuracy, quality, and productivity standards.
- Support training and mentoring of new reviewers.
- Stay current on clinical guidelines and maintain licensure.
- Cross-train on various claim types to meet client needs.
- Contribute as a subject matter expert and assist with reports, analysis, and projects.
- Demonstrate expertise in chart audits, medical review, and quality improvement.
What we're looking for
- Active, unrestricted RN licensure from the United States and in the state of primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
- 5+ years clinical experience in acute setting
- 3+ years medical record review or Quality auditing experience
- Expert level experience applying MCG and/or InterQual criteria
- Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of determinations.
- Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations
What you should expect in this role
- Remote position within the U.S.
- May require occasional travel
#LI-AC1 #LI-REMOTE The pay range for this position is $64,500.00 - $92,200.00 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. Apply tot his job Apply To this Job