Senior Professional Nurse- Remote

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.

Conduct objective desk and medical record audits to verify service documentation, determine appropriate administration, and validate coding/billing accuracy. Interview providers and health plan members to assess potential fraud, waste, or abuse. Collaborate with internal teams (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to collect relevant documentation for investigations. Identify potential healthcare fraud, waste, and abuse by analyzing aberrant coding and billing patterns through utilization review. Communicate effectively with physicians and healthcare professionals during investigations. Prepare accurate and timely reports detailing audit findings for internal and external stakeholders. Provide provider education on best practices (e.g., coding) based on national/local guidelines, contractual obligations, and regulatory requirements. Identify process improvement opportunities and recommend system enhancements to optimize investigative outcomes and performance.