Clinical Quality Nurse Reviewer, Sr. Specialist...

<span class="jobdescription"><p><span style="font-size:12.0pt;font-family:arial, helvetica, sans-serif">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.</span></p> <p> </p><div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:18.0px;word-wrap:break-word"><h2 style="font-size:1.0em;margin:0.0px"><b>Summary</b></h2> </div><div><p style="margin:0.0in 0.0in 8.0pt;line-height:107%;font-size:11.0pt;font-family:Aptos, sans-serif"><span style="font-size:12.0pt;color:black"><span style="line-height:107%;font-family:Arial, sans-serif">We are seeking a talented individual for a</span> Clinical <span style="line-height:107%;font-family:Arial, sans-serif">Q</span><span style="line-height:107%;font-family:Arial, sans-serif">uality Nurse Reviewer, Sr. Specialis</span><span style="line-height:107%;font-family:Arial, sans-serif">t </span><span style="line-height:107%;font-family:Arial, sans-serif">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. </span></span></p></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:18.0px;word-wrap:break-word"><h2 style="font-size:1.0em;margin:0.0px"><b>Your role in our mission</b></h2> </div><div><ul> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Conduct QA checks on complex clinical claim reviews.</span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Analyze claims and medical records using approved guidelines.</span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Document review findings clearly and accurately.</span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Identify quality trends and support improvements through training and education.</span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Ensure reviews meet accuracy, quality, and productivity standards.</span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Support training and mentoring of new reviewers.</span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Stay current on clinical guidelines and maintain licensure.</span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Cross-train on various claim types to meet client needs.</span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Contribute as a subject matter expert and assist with reports, analysis, and projects.</span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Demonstrate expertise in chart audits, medical review, and quality improvement.</span></li> </ul></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:18.0px;word-wrap:break-word"><h2 style="font-size:1.0em;margin:0.0px"><b>What we're looking for</b></h2> </div><div><ul> <li><span style="font-size:12.0pt;font-family:arial, helvetica, sans-serif;color:black">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</span></li> <li><span style="font-size:12.0pt;line-height:105%;font-family:arial, helvetica, sans-serif;color:black">5+ years clinical experience in acute setting</span></li> <li><span style="font-size:12.0pt;line-height:105%;font-family:arial, helvetica, sans-serif;color:black">3+ years medical record review or Quality auditing experience</span></li> <li><span style="font-size:12.0pt;line-height:105%;font-family:arial, helvetica, sans-serif;color:black">Expert level experience applying MCG and/or InterQual criteria </span></li> <li><span style="font-size:12.0pt;line-height:105%;font-family:arial, helvetica, sans-serif;color:black">Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of determinations.</span></li> <li><span style="font-size:12.0pt;line-height:105%;font-family:arial, helvetica, sans-serif;color:black">Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations</span></li> </ul></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:18.0px;word-wrap:break-word"><h2 style="font-size:1.0em;margin:0.0px"><b>What you should expect in this role</b></h2> </div><div><ul> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">Remote position within the U.S. </span></li> <li><span style="font-family:arial, helvetica, sans-serif;color:black;font-size:12.0pt">May require occasional travel </span></li> </ul> <p> </p> <p> </p> <p><span style="font-family:arial, helvetica, sans-serif;font-size:12.0pt">#LI-AC1</span></p> <p><span style="font-family:arial, helvetica, sans-serif;font-size:12.0pt">#LI-REMOTE</span></p></div></div></div><p> </p> <p><span style="font-size:12.0pt;font-family:arial, helvetica, sans-serif">The pay range for this position is $64,500.00 - $92,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a <a href="https://jobs.gainwelltechnologies.com/content/benefits/?locale=en_US">401(k) employer match, comprehensive health benefits</a>, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.</span></p> <p><span style="font-size:12.0pt;font-family:arial, helvetica, sans-serif"> </span></p> <p><span style="font-size:12.0pt;font-family:arial, helvetica, sans-serif">We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our <a href="https://www.gainwelltechnologies.com/">company website</a> and visit our <a href="https://jobs.gainwelltechnologies.com/">Careers site</a> for all available job role openings.</span></p> <p><span style="font-size:11.0pt"><span style="font-family:Calibri"> </span></span></p> <p><span style="font-size:8.0pt"><span style="font-family:Arial, Helvetica, sans-serif"><em style="font-style:italic">Gainwell Technologies <span style="color:#32363a">is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. </span></em></span></span></p> </span>