Sr. Nurse Reviewer - Provider Relations

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 Senior Nurse Reviewer – Provider Relations to respond to Acute Hospital provider questions and concerns regarding matters pertaining to Pre-Admission Screening, Prepayment Review, and Post Payment Review.  A key component of this role is maintaining effective working relationships with providers and the client, implementing annual review process with each provider and meeting with providers virtually or onsite to review results and provide education.

Your role in our mission

• Implement and schedule annual review meetings virtually or on-site at each Acute Hospital that is geared towards the hospital’s specific needs.  Submit to the client the upcoming quarterly schedule and reports reviewed with hospitals from the preceding quarter.
• Perform quarterly and annual assessments of the results of data analysis and reporting functions for each Acute Hospital.
• Implement procedures for investigating and resolving hospital and members’ complaints and inquiries.
• Respond, verbally or in writing, as appropriate, to hospital and member inquiries or complaints within the prescribed deadline.
• Make recommendations to Gainwell management to prevent future issues and complaints.
• Assists with Pre-Admission Screening, Prepayment Review, and Post Payment Reviews to keep abreast of the current review process and to meet client needs.
• Project Management as requested by clinical leadership or Program Director.

What we're looking for

• Active, Unrestricted Massachusetts RN license required or within 60 days of hire.
• 3+ years clinical experience including Acute Hospital experience and Utilization Management experience required.
• Experience using InterQual criteria required.
• Program Management experience preferred.
• Working knowledge of Pre-Admission Screening, Prepayment Review, and Post Payment Review.
• Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of clinical review determinations.
• Excellent oral communication skills with particular emphasis on verbally presenting clinical review processes and results.
• Ability to work proficiently in Microsoft Word, Excel, and Power Point.
• Ability to multi-task in a fast-paced work environment.

What you should expect in this role

• Home based position and you must have a work location within the continental US.
• This position requires that you provide high speed internet connection and a work environment free from dist