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Appeals Nurse Reviewer - Remote

Date:  May 9, 2023

Any city, VA, US, 99999

Req ID:  17763

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.



As a Appeals Nurse Reviewer - Remote at Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve — a community’s most vulnerable. We are seeking a talented individual for a Clinical Appeals Reviewer 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 hearings.

Your role in our mission

  • Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.
  • Analyzes and reviews 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 participates in hearings in conjunction with the Medical Director.
  • 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.
  • Assists with appeal data analysis, reporting and feedback.
  • Engages with the Quality team and incorporating Quality feedback into individual and team appeals work processes

What we're looking for

  • Knowledge of clinical guideline criteria and best practices in clinical care, including possessing and maintaining an active and unrestricted RN license in your state of work
  • Knowledge of Milliman or Interqual criteria and HIPAA privacy rules
  • Active unrestricted RN license OR Certified Professional Coder (CPC) OR Certified Coding Specialist (CCS) OR Certified Professional Medical Auditor (CPMA) required
  • 5+ years clinical experience or 5+ years medical record coding experience required
  • 2+ years medical record auditing experience preferred

What you should expect in this role

  • 100% work-from-home with occasional co-location with team (~1 time per month) 
  • All equipment provided but you must have internet access









The pay range for this position is $61,500.00 - $87,900.00 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 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.

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