Clinical Quality Nurse Auditor (Remote Registered Nurse)

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

As a Clinical Quality Nurse Auditor (Remote Registered Nurse) at Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve — a community’s most vulnerable. Connect your passion with purpose, teaming with people who thrive on finding innovative solutions to some of healthcare’s biggest challenges. Here are the details on this position. 

We are seeking a talented individual for a Clinical Quality Nurse Auditor who is responsible for performing on-going assessments of the quality of work performed by clinical staff such as Nurse Reviewer and Clinical Auditors. This person is responsible for complex quality reviews to determine if decision by review staff matches medical records and approved review methodologies.  This person is also responsible for working closely with the other clinical Supervisors and Managers to ensure that Clinical Reviewers are producing work that meets internal quality standards.

Your role in our mission

It takes knowledge and experience to perform the role of reviewing Medicaid billing claims and helping our clients recover Medicaid funds to provide healthcare for those who need it most.

• Perform clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines
• Conduct retrospective reviews, pre-certification and prior authorization; justify your findings by providing a documented rationale 
• Determine approval or initiate a referral to a physician consultant; review the rationales provided for your reference and future use
• Enhance your knowledge by actively cross-training to review multiple claim types and clients  to help Gainwell build a flexible, skilled workforce that meets diverse client needs 
• Keep growing in your role by staying up to date on CEUs to maintain your RN license and coding certifications

What we're looking for

• 5 or more years of experience working in an inpatient hospital setting and with 2+ years of experience analyzing and evaluating medical information, reviewing charts and applying clinical review guidelines to deliver accurate rationales
• Knowledge of clinical guideline criteria and best practices in clinical care, including possessing and maintaining an active and unrestricted RN license in your state of work
• Knowledge of Milliman or Interqual criteria and HIPAA privacy rules
• Strong written communication and analytical skills, with an emphasis on towards writing clear, accurate and concise clinical decision rationales in support of findings using a computer 
• Strong team player with an ability to build relationships within the company and externally with clients as needed

What you should expect in this role

• 100% work-from-home with occasional co-location with team (~1 time per month) 
• Full-time (40 hours per week) Monday through Friday schedule
• Benefits start on first day of employment (medical, dental, vision)
• In order to effectively work as a remote worker (work from home) with Gainwell, 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 or click here.  
• Video cameras must be used during all interviews, as well as during the init