Nurse Reviewer - Massachusetts RN License

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.

We are seeking a talented individual for a Nurse Reviewer (RN) to support our Massachusetts contract. Due to recent turnover, there is an immediate need for nurses who hold an active Massachusetts RN license. This role involves performing 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 as defined by review methodologies specific to the contract. Responsibilities include accessing proprietary systems to audit medical records, documenting findings accurately, and providing policy and regulatory support for determinations. This position is intended for pipelining, and applications will be accepted on an ongoing basis.

Reviews and interprets medical records against criteria to assess appropriateness and reasonableness of care; applies critical thinking to ensure documentation supports medical necessity while meeting production and quality goals. Documents decisions and rationale clearly to support findings or no findings. Determines approvals or refers cases to physician consultants; processes consultant decisions and ensures denial reasons are detailed and completed within deadlines. Performs prior authorization, precertification, and retrospective reviews; prepares decision letters as required. Assists management in training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education. Maintains current knowledge of clinical criteria guidelines and completes CEUs to maintain RN licensure. Attends trainings and meetings to stay current on clinical policies, procedures, rules, and regulations. Cross-trains to review multiple claim types to maintain workforce flexibility. Recommends and helps implement process improvements, new audit concepts, and technology solutions to enhance production, quality, and client satisfaction.