Medical Reviewer (Registered Nurse) - Remote CA

Summary

Gainwell Technologies is seeking a Medical Reviewer (Registered Nurse) to support Medical Review Services for California healthcare programs. In this role, you will use your professional nursing experience and clinical judgment to review medical records, healthcare services, claims, and authorization requests.

Your role in our mission

• Review and interpret medical records and clinical documentation to determine medical necessity and appropriateness of healthcare services.
• Provide clinical review support for Treatment Authorization Requests (TARs) and other authorization activities.
• Support medical review activities related to medical policy, claim adjudication, drug utilization review, and other healthcare program requirements as assigned.
• Apply professional nursing principles, clinical judgment, medical policies, and established utilization guidelines when completing reviews.
• Review medical documentation to determine whether requested services, procedures, supplies, and equipment meet applicable coverage and clinical requirements.
• Document review findings, decisions, and supporting clinical rationale accurately and timely.
• Determine approvals within established guidelines or refer cases to physicians or other appropriate clinical professionals when additional review is required.
• Apply knowledge of hospital routines, medical services, medical supplies, and their appropriate clinical uses when conducting reviews.
• Collaborate with physicians, pharmacists, nurses, and other healthcare professionals to support accurate medical review determinations.
• Maintain current knowledge of applicable clinical criteria, medical policies, procedures, and regulatory requirements.
• Meet established quality, accuracy, and productivity standards.

What we're looking for

• Active and unrestricted Registered Nurse (RN) license to practice in the State of California, in good standing.
• Minimum of two (2) years of professional nursing experience.
• Possession of a Master’s Degree in Nursing may substitute for one (1) year of the required professional nursing experience.
• Knowledge of professional nursing principles and techniques, hospital routines, and medical supplies and their uses.
• Training and/or certification in wound and ostomy care preferred.
• Strong clinical judgment and ability to interpret medical records and supporting clinical documentation.
• Experience with medical review, utilization review, medical necessity review, prior authorization, Treatment Authorization Requests (TARs), or claims review preferred.
• Strong written and verbal communication skills.

What you should expect in this role

• Full-time position.
• Remote work environment.
• Monday through Friday work schedule.
• Work primarily from your home office while supporting Medical Review Services for California healthcare programs.
• Spend the majority of your day reviewing medical, clinical, claim, authorization, and/or supporting documentation relevant to your area of expertise.
• Work independently while collaborating with physicians, pharmacists, nurses, other clinical specialists, operations teams, and business partners.
• Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
• Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status, as applicable.
• Maintain knowledge of applicable medical policies, coverage requirements, clinical standards, and regulatory guidelines.
• Meet established quality, accuracy, productivity, and turnaround-time expectations.
• Receive ongoing training and support related to program requirements, systems, policies, and medical review processes.

This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis.

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