Service Utilization Review Nurse (Hybrid, Rhode Island)

Date: Dec 9, 2024

Location:

Warwick, RI, US, 02886-1782

Req ID: 28274

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

Gainwell Technologies SUR Nurses apply clinical expertise to perform case reviews of Medicaid claims data to identify potential fraud, abuse, and quality of care concerns. Reviews are conducted in accordance with RI Executive office of Health and Human Services (RI EOHHS) policies. This position is intended for pipelining. We will accept applications on an ongoing basis.

Your role in our mission

• Applies clinical knowledge to Medicaid claim data to identify possible issues of fraud or abuse of Medicaid benefits, quality of care concerns or non-compliance with existing policy.

• Researches individual cases, summarizes the findings and presents recommendations to the customer using independent clinical judgement and established protocols.

• The recommendations may include recoupment or adjustment of claims, referral to the Medicaid Fraud Control Unit (MFCU), referral to the Department of Health or other agencies. The analyst may be required to testify in court to present case findings.

• Cases are often complex requiring in depth research of community medical standards, existing policy and procedures and knowledge of claims processing.

• Presentations of findings are both written and oral and are shared with a wide audience.

What we're looking for

• Registered Nurse with at least 5 years of clinical experience. Must have (or be willing to obtain) an RN license in the state of Rhode Island without assistance from Gainwell. Will be verified during post hire background check

• Excellent verbal, written and analysis skills. Will be required to work closely with client contacts

• Working knowledge of applications such as Excel, Word, Outlook, etc.

• Familiarity with claim review and coding experience (CPT, ICD9, HCPCS) necessary

• Able to work within a small team in our Warwick, RI office

What you should expect in this role

This is a full-time permanent regular salaried (W-2) employee position.
- Monday through Friday work schedule (40 hours per week).
- Our hybrid schedule is working from home on most days but requires working in the Rhode Island office during initial new hire training and at least twice per month.
Upward career advancement is possible and encouraged.
Health (medical, dental, vision) and paid time off benefits start on day 1 of employment.
Company match 401K and other benefits available within months of starting.
Computer for work company-provided.
For all hybrid and remote positions 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.
Video cameras must be used during all interviews, as well as during the initial week of orientation if hired.

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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 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.