Job Description

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 Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings.

Your role in our mission

• Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.
• Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
• Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
• Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
• Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Gainwell does not pay for this.
• 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 reviews of multiple claim types to provide a flexible workforce to meet client needs.

What we're looking for

• Unrestricted RN license or Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) preferred
• 5+ years clinical experience or 5+ years medical record coding experience preferred
• Working knowledge of the appeals and hearings process, with emphasis on excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
• Experience using MCG or InterQual criteria preferred
• Ability to multi-task in a fast-paced production environment while providing clear communication around appeals and hearings.

What you should expect in this role

• This is a full-time permanent regular salaried (W-2) employee position.
• 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 and other company-provided items.
  • internet services are not provided nor paid for by Gainwell
• Monday through Friday work schedule.
• This position is fully remote (working from home) however travel to appeals and court hearings are required when necessary.
• For all 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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#LI-REMOTE

This position is intended for pipelining. We will accept applications on an ongoing basis.

The pay range for this position is $64,500.00 - $80,000 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.

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