Nurse Reviewer (Appeals and Hearings)

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 Nurse Reviewer Appeals and Hearing to coordinate and perform all appeal-related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; preparing case files and case summaries for hearings; and participate in virtual and on-site hearings. Your role in our mission • Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. • Analyze and review appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. • Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. • Assists management with training new reviewers to include daily monitoring, mentoring, feedback, and education. • Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. • 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 reviews of multiple claim types to provide a flexible workforce to meet client needs. What we're looking for • Unrestricted RN license or Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) preferred. • 5+ years of clinical experience or 5+ years of medical record coding experience preferred. • Working knowledge of the appeals and hearings process and experience using MCG or InterQual criteria preferred. • Excellent oral and written communication skills including the ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations with particular emphasis on verbally presenting case summaries and decisions. • Ability to multi-task in a fast-paced production environment. What you should expect in this role • Remote (Work from Home) • Up to 25% Travel for onsite hearing testimony • In order to effectively work as a teleworker 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. This position is intended for pipelining. We will accept applications on an ongoing basis. The pay range for this position is $61,500.00 - $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 Apply Job!