Medical Reviewer, Registered Nurse
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Job Description
Medical Reviewer (Registered Nurse) reviewing California healthcare records, claims, and authorizations for Gainwell Technologies. Determining medical necessity and supporting healthcare program compliance remotely.
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
- Apply professional nursing principles, clinical judgment, medical policies, and established utilization guidelines when completing reviews
- Review documentation to determine whether requested services, procedures, supplies, and equipment meet 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
- Apply knowledge of hospital routines, medical services, medical supplies, and appropriate clinical uses
- Collaborate with physicians, pharmacists, nurses, and other healthcare professionals
- Maintain current knowledge of clinical criteria, medical policies, procedures, and regulatory requirements
- Meet established quality, accuracy, productivity, and turnaround-time standards
- Work primarily from a home office supporting Medical Review Services for California healthcare programs
- Navigate multiple systems and applications to complete reviews and document findings
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
- Ability to navigate multiple computer systems and applications
- Ability to maintain required professional licenses, certifications, and credentials in active, unrestricted, and good-standing status
Benefits:
- Flexible hours
- Work-life balance
- Continuous learning and career development
- Flexible vacation policy
- 401(k) employer match
- Comprehensive health benefits
- Educational assistance
- Leadership and technical development academies
- Ongoing training and support
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