Clinical Quality Nurse Reviewer, Sr. Specialist

apartment Gainwell Technologies LLC location_onIrving, TX

$64,500 - $92,200 / YEAR

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 Clinical Quality Nurse Reviewer, Sr. Specialist 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. Your role in our mission • Conduct quality assurance checks on complex clinical claim reviews and ensure accuracy of determinations. • Analyze claim data and medical records using approved clinical guidelines; document findings clearly. • Provide detailed quality review results for reporting and trend analysis; help identify quality issues and support remediation efforts, including developing training materials. • Ensure all aspects of the clinical review are fully addressed while meeting production and quality standards. • Support training of new reviewers through monitoring, mentoring, and feedback. • Maintain up-to-date knowledge of clinical guidelines and complete required CEUs to keep RN license active. • Participate in training sessions and meetings to strengthen understanding of clinical policies and procedures. • Cross-train to review multiple claim types to support business needs. • Serve as a subject matter expert and assist with proposals, projects, reporting, and data analysis. • Consistently meet performance expectations and demonstrate strong experience in medical review, chart audits, and quality improvement. What we're looking for 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 Associate degree required; bachelor’s degree preferred. 5+ years clinical experience in acute setting 3+ years medical record review/auditing experience preferred Expert level experience applying MCG and/or InterQual criteria Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of determinations. Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations. Ability to multi-task in a fast-paced production environment. What you should expect in this role Remote within the U.S. Applications for this posting will be accepted until January 12, 2026. 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 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. 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 company website and visit our Careers site for all available job role openings. Gainwell Technologies 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.

RN

Utilization Review

Full-time

Clinical Quality Nurse Reviewer, Sr. Specialist

apartment Gainwell Technologies LLC location_onTucker, GA

$64,500 - $92,200 / YEAR

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 Clinical Quality Nurse Reviewer, Sr. Specialist 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. Your role in our mission Perform QA checks on complex clinical claim reviews Review and analyze claim data and medical records using approved guidelines Document determinations clearly and concisely Report quality findings for trending and performance insights Identify trends and support remediation through training or educational materials Ensure documentation accuracy while meeting quality and production goals Assist with onboarding and mentoring new reviewers Maintain current knowledge of clinical criteria and required CEUs Attend trainings and meetings to stay aligned with policies and regulations Cross-train on multiple claim types to support workload flexibility Serve as SME for proposals and department initiatives Support projects, reporting, and data analysis as needed Consistently meet productivity and quality targets Apply clinical judgement to evaluate medical information and review outcomes What we're looking for Active, unrestricted RN license in the U.S. and in the candidate’s state of primary residence, with a current multistate compact (NLC) license required. Associate degree required; bachelor’s degree preferred. 5+ years clinical experience in acute setting 3+ years medical record review/auditing experience preferred Expert level experience applying MCG and/or InterQual criteria Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of determinations. Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations. Ability to multi-task in a fast-paced production environment. What you should expect in this role Work Arrangement: Remote within the United States Travel Requirement: Up to 10% Position Type: Full-time job Applications for this posting will be accepted until February 4, 2026. 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 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. 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 company website and visit our Careers site for all available job role openings. Gainwell Technologies 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.

RN

Utilization Review

Full-time

Utilization Review Nurse- Remote

apartment Gainwell Technologies LLC location_onNC

$65,000 - $78,000 / YEAR

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 skilled Utilization Review Nurse to conduct prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines. This involves reviewing medical documentation, accurately documenting findings, and ensuring policy compliance. Your role in our mission Review admissions, procedures, services, and supplies for medical necessity and appropriateness, meeting quality and production goals. Use clinical criteria for decision-making, referring complex cases to Medical Directors when needed. Engage with providers to gather clinical information, apply guidelines, and make determinations. Document findings and rationale in medical management systems. Assist in training new nurses, provide feedback, and stay updated on clinical guidelines. Maintain RN license and meet continuing education requirements. What we're looking for Active RN license. 3+ years of inpatient clinical experience. 1+ year in prior authorization reviews using InterQual or MCG. Strong written communication skills in a fast-paced setting. Proficient in Microsoft Office and other computer applications. What you should expect in this role Home-based position. High-speed internet and a distraction-free workspace required. Core hours: 8:00 AM - 6:00 PM ET, with potential for extended hours. Occasional travel (up to 10%) based on business needs. This position is for pipeline purposes, and we welcome applications on an ongoing basis. #LI-AC1 #LI-REMOTE The pay range for this position is $65,000.00 - $78,000.00 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 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. 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 company website and visit our Careers site for all available job role openings. Gainwell Technologies 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.

RN

Utilization Review

Full-time

Nurse Reviewer - Massachusetts RN License

apartment Gainwell Technologies LLC location_onMA

$78,000 - $85,000 / YEAR

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 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. Summary Your role in our mission Your role in our mission 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Recommends and helps implement process improvements, new audit concepts, and technology solutions to enhance production, quality, and client satisfaction. What we're looking for What we're looking for Proficient in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers. Active, unrestricted RN licensure in Massachusetts required; compact multistate RN license strongly preferred. Verification will occur during post-offer background check. Minimum of 5+ years clinical experience in an inpatient hospital setting required. Minimum of 2+ years utilization review or claims auditing experience required. Experience with Milliman or InterQual criteria required. Ability to work standard business hours with frequent interactions across teams and departments. Flexibility to work extended hours when needed to support business demands. Proficient in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers. Proficient in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers. Active, unrestricted RN licensure in Massachusetts required; compact multistate RN license strongly preferred. Verification will occur during post-offer background check. Active, unrestricted RN licensure in Massachusetts required; compact multistate RN license strongly preferred. Verification will occur during post-offer background check. Minimum of 5+ years clinical experience in an inpatient hospital setting required. Minimum of 5+ years clinical experience in an inpatient hospital setting required. Minimum of 2+ years utilization review or claims auditing experience required. Minimum of 2+ years utilization review or claims auditing experience required. Experience with Milliman or InterQual criteria required. Experience with Milliman or InterQual criteria required. Ability to work standard business hours with frequent interactions across teams and departments. Ability to work standard business hours with frequent interactions across teams and departments. Flexibility to work extended hours when needed to support business demands. Flexibility to work extended hours when needed to support business demands. What you should expect in this role What you should expect in this role This is a fully remote position. Candidates may reside anywhere within the United States but must hold and maintain an active Massachusetts RN license. Full-time, permanent salaried (W-2) employee position, not a contract or short-term role. Health benefits (medical, dental, vision) and paid time off begin on the first day of employment. Standard Monday through Friday work schedule. Remote position; employees must be located within the continental U.S. while working. Work environment must be private, free of distractions, loud noises, and recording devices. May require up to 10% travel depending on business needs. This is a fully remote position. Candidates may reside anywhere within the United States but must hold and maintain an active Massachusetts RN license. Full-time, permanent salaried (W-2) employee position, not a contract or short-term role. Full-time, permanent salaried (W-2) employee position, not a contract or short-term role. Health benefits (medical, dental, vision) and paid time off begin on the first day of employment. Health benefits (medical, dental, vision) and paid time off begin on the first day of employment. Standard Monday through Friday work schedule. Standard Monday through Friday work schedule. Remote position; employees must be located within the continental U.S. while working. Remote position; employees must be located within the continental U.S. while working. Work environment must be private, free of distractions, loud noises, and recording devices. Work environment must be private, free of distractions, loud noises, and recording devices. May require up to 10% travel depending on business needs. May require up to 10% travel depending on business needs. #LI-AC1 #LI-REMOTE The pay range for this position is $78,000.00 - $85,000.00 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 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. 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 company website and visit our Careers site for all available job role openings. Gainwell Technologies 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. Gainwell Technologies 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.

RN

Utilization Review

Full-time

Clinical Quality Nurse Reviewer, Sr. Specialist- Remote

apartment Gainwell Technologies LLC location_onFL

$64,500 - $92,200 / YEAR

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 Clinical Quality Nurse Reviewer, Sr. Specialist 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. Your role in our mission Conduct QA checks on complex clinical claim reviews. Analyze claims and medical records using approved guidelines. Document review findings clearly and accurately. Identify quality trends and support improvements through training and education. Ensure reviews meet accuracy, quality, and productivity standards. Support training and mentoring of new reviewers. Stay current on clinical guidelines and maintain licensure. Cross-train on various claim types to meet client needs. Contribute as a subject matter expert and assist with reports, analysis, and projects. Demonstrate expertise in chart audits, medical review, and quality improvement. What we're looking for 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 5+ years clinical experience in acute setting 3+ years medical record review or Quality auditing experience Expert level experience applying MCG and/or InterQual criteria Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of determinations. Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations What you should expect in this role Remote position within the U.S. May require occasional travel #LI-AC1 #LI-REMOTE 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 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. 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 company website and visit our Careers site for all available job role openings. Gainwell Technologies 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.

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