Utilization Review Nurse- Remote

Summary

We are seeking a skilled Utilization Review Nurse to conduct prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines.

Responsibilities

• Review admissions, procedures, services, and supplies for medical necessity and appropriateness, meeting quality and production goals.
• Use clinical criteria for decision-making, referring complex cases to Medical Directors when needed.
• Engage with providers to gather clinical information, apply guidelines, and make determinations.
• Document findings and rationale in medical management systems.
• Aid in training new nurses, providing feedback, and staying updated on clinical guidelines.
• Maintain RN license and meet continuing education requirements.

Requirements

• Active, unrestricted RN licensure in the U.S. and primary state of residence, plus an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC); verification required during post-offer background check.
• 3+ years of inpatient clinical experience.
• 1+ year in prior authorization reviews using InterQual or MCG.
• Strong written communication skills in a fast-paced setting.
• Proficient in Microsoft Office and other computer applications.

Qualifications

• Active, unrestricted RN licensure in the U.S. and primary state of residence, plus an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC); verification required during post-offer background check.
• 3+ years of inpatient clinical experience.
• 1+ year in prior authorization reviews using InterQual or MCG.
• Strong written communication skills in a fast-paced setting.
• Proficient in Microsoft Office and other computer applications.

Skills

• Strong written communication skills in a fast-paced setting.
• Proficient in Microsoft Office and other computer applications.

Benefits

• Home-based role available to applicants residing anywhere in the U.S.
• High-speed internet and a distraction-free workspace required.
• Core hours: 8:00 AM - 6:00 PM ET, with potential for extended hours.
• Occasional travel (up to 10%) based on business needs.

Pay

The pay range for this position is $78,000.00 to $88,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Schedule

In this role, you will work core hours from 8:00 AM - 6:00 PM ET, with potential for extended hours.

Benefits

• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Education assistance.

Company Culture

• Gainwell Technologies is an Equal Opportunity Employer.
• We value work flexibility, learning, and career development.