Remote Nurse Reviewer (RN) – Clinical Utilization Review

About the role

Gainwell is seeking a Registered Nurse to join its remote team as a Nurse Reviewer. You will apply clinical expertise to evaluate medical records, ensuring services meet established medical necessity criteria and utilization guidelines.

Key responsibilities

• Review and interpret medical records against contract‑specific clinical criteria, coverage policies, and utilization guidelines.
• Document findings clearly, determine approvals, or refer cases to physician consultants.
• Process prior authorizations, precertifications, and retrospective reviews, and prepare decision letters as needed.
• Mentor and train new Nurse Reviewers, providing daily monitoring and feedback.
• Stay current on clinical criteria, complete CEUs for RN licensure, and attend trainings on policies and regulations.
• Identify and recommend process improvements, new audit concepts, and technology solutions.

Required profile

• Active, unrestricted RN license in the U.S. and a compact multistate RN license (NLC).
• Minimum 5 years of inpatient hospital clinical experience.
• At least 2 years of utilization review or claims auditing experience.
• Familiarity with Milliman or InterQual criteria.

Required skills

• Proficiency with Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers.
• Strong computer and typing skills.
• Experience using Milliman or InterQual clinical criteria tools.

What we offer

• Flexible remote work schedule.
• Focus on work‑life balance, continuous learning, and career development.
• Opportunities to influence process improvements and technology adoption.