Utilization Review Nurse / Prior Authorization

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 Utilization Review Nurse who will be responsible for performing prior authorization, prospective, concurrent, and retrospective 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, prospective, concurrent, and retrospective 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 RN license required; Kentucky or compact license preferred
• 5+ years clinical experience in an inpatient hospital setting required
• 2+ years utilization review experience with at least 1 year working in a clinical call center environment required
• Experience in prior authorization reviews utilizing InterQual or Milliman criteria while working under expedited timelines
• Ability to multitask between computer-based desk reviews and telephonic reviews
• Excellent verbal skills with the ability to present a positive and professional phone voice to all incoming and outbound calls.
• Excellent written skills with the ability to write clearly and concisely in a fast-paced work environment.
• Demonstrated proficiency in computer skills, and typing, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers, etc.

What you should expect in this role

• Home based position and you must have a work location within the continental US
• This position requires that you provide a high-speed internet connection and a work environment free from distractions
• 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
• May be required to work extended hours to ensure reviews are completed timely
• May be required to travel at least 10% of time based on business needs

#LI-NB1

#LI-REMOTE

The pay range for this position is $55,600.00 - $79,400.00 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.