Medical Reviewer (Registered Nurse) - Remote CA

About the role

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.

Responsibilities

• 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.

Requirements

• 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.

Schedule

• Full-time position.
• Remote work environment.
• Monday through Friday work schedule.

Pay

The pay range for this position is $70,000 - $100,000 per year. The base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Benefits

• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies to help build your skills and capabilities.