Clinical Quality Nurse Reviewer, Sr. Specialist - (RN Remote in US)

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 Clinical Quality Nurse Reviewer, Sr. Specialist who is responsible for performing on-going quality assurance audits of the work performed by clinical staff. This person is responsible for complex quality reviews to determine if decision by review staff matches medical records and approved review methodologies. Responsibilities include reviewing documentation to ensure all aspects of the review audit have been addressed properly and accurately. Performing inter-rater reliability assessments and quality assurance auditors for multiple review types including Place of Service, Level of Care, Readmissions, Utilization Management and other specialty reviews

Your role in our mission

• Perform Quality Assurance checks on final review work of complex clinical claims.
• Review and analyze claim data and synthesize medical record using approved clinical guidelines.
• Identifies quality trends and works with leadership to develop remediation activities.  This include developing educational materials and leading training sessions to improving the quality of our clinical solutions.
• Analyzes and reviews documentation to ensure all aspects of the review have been addressed properly and accurately while maintaining production goals and quality standards.
• Maintains current knowledge of clinical criteria guidelines; successfully completes required CEUs to maintain RN license
• 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.
• Consistently achieves productivity and quality performance standards established by management.
• Demonstrated experience in medical review, chart audits and quality improvement processes.
• Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of determinations.
• Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations.
• Ability to multi-task in a fast-paced production environment.

What we're looking for

• Active, unrestricted RN licensure from the United States and in the state of primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
• Associate degree required; bachelor’s degree preferred.
• 5+ years clinical experience in acute setting
• 3+ years medical record review/auditing experience preferred
• Expert level experience applying MCG and/or InterQual criteria

What you should expect in this role

• This is a full-time permanent regular salaried (W-2) employee position.