Associate Manager, Clinical Claim Review- Remote

$85,000 - $110,000 / 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 an Associate Manager, Clinical Claim Review who is responsible for supervising the day-to-day prepay, post-pay, prior authorization, and medical record review activities of a multidisciplinary team of Coders, Clinical DRG Auditors, and Nurse Reviewers. Oversees and manages the daily operations of the team by leading, assigning work, ensuring productivity and quality metrics are achieved, and analyzing production and workflow/processes to increase efficiency and quality. Consistently demonstrates effective change management by communicating changes timely and effectively; building commitment and overcoming resistance; supporting those affected by change; monitoring transition and evaluating results.

Your role in our mission

Responsible for oversight and hiring of staff, retaining top talent, performance management, coordinating training and education, and providing leadership and mentorship to staff to build and improve skills. Delivers best-in-class practices to enhance efficiency, quality, and customer satisfaction.
Monitor aging inventory, workload, assignments, productivity, and quality to ensure service level agreements, contract deliverables, and timelines are met.
Evaluate and analyze productivity, utilization, efficiency, finding rates, savings, appeal overturn rate, and reviews completed by staff to identify opportunities for process improvements.
Meet with clients and providers to discuss complex cases, trend analysis, and exit and/or settlement conferences.
Serve as a Subject Matter Expert to assess new tools, automation, product development, and clinical readiness; act as a resource for resolving escalated issues; and coach and mentor staff to develop a high-performing team.
Analyze reports and data to identify trends and resources that improve the delivery of clinical review services.
Manage and evaluate individual and team performance and take appropriate action to meet and/or exceed performance standards.
Perform other duties as assigned.

What we’re looking for

Active, unrestricted RN license in the United States and in the primary state of residence; active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
Bachelor’s degree in business, healthcare administration, or a related field preferred.
5+ years of healthcare experience with increasing responsibility required.
3+ years of utilization review or healthcare auditing experience required.
2+ years of management or supervisory experience preferred.
Demonstrates a thorough understanding of clinical criteria and clinical review judgment.

What you should expect in this role

Remote (Work from Home)
Up to 20% Travel

Applications will be accepted through April 17, 2026.

The pay range for this position is $85,000.00 - $110,000.00 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 defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.

Share this job

Related Jobs

Utilization Review Manager

UHS Gulfport, MS

Responsibilities We are now offering a $5,000 sign-on bonus for our Utilization Review Manager opening! Gulfport Behavioral Health System is an acute behavioral health hospital on the Mississippi Gulf Coast providing inpatient, partial hospitalization and outpatient services to children, adolescents, and adults. We have served our community for over 30-years and our Patriot Support Program provides inpatient around-the-clock mental health treatment to help military members and their families, veterans, and first responders cope with stressful issues every day. Visit us online at: https://gulfportbehavioral.com The Utilization Review Manager: will assume responsibility for the functioning of the Utilization Review Department and provide utilization review services in a manner consistent with the philosophy and objectives of the facility; evaluates patient medical records to determine severity of patient’s illness and determines the appropriateness of level of care; serves as liaison for patients and hospital with insurance companies; negotiates and advocates for patient length of stay and level of care; oversees utilization review activities with other departments to ensure reimbursement for services provided by the hospital. Benefit Highlights: Challenging and rewarding work environment Career development opportunities within UHS and its Subsidiaries Competitive Compensation Excellent Medical, Dental, Vision and Prescription Drug Plan 401(K) with company match and discounted stock plan Generous Paid Time Off Free Basic Life Insurance Tuition Reimbursement If you would like to learn more about this position before applying, please contact Madison Reddell, Clinical Recruiter, at Madison.Reddell@uhsinc.com or by phone at (484)-584-2790. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500® corporation. Headquartered in King of Prussia, PA, UHS has 101,500 employees. Through its subsidiaries, UHS operates 29 acute care inpatient facilities, 346 behavioral health inpatient facilities and 168 outpatient and other facilities in 40 U.S. states, Washington, D.C., Puerto Rico and the United Kingdom. Qualifications Education : Bachelor degree in Nursing or Master’s Degree in human services field preferred. Experience: Minimum of 2 years clinical experience and 1 year of management experience with case management and the utilization review process including concurrent reviews. Previous continuum of care experience highly preferred. Licensure: Current license in the state of Missisippi, including RN, LMSW, LMFT, LPC EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

UTILIZATION REVIEW MANAGER

UHS Gulfport, MS

Responsibilities Gulfport Behavioral Health System (a UHS facility): Gulfport Behavioral Health System, is a 92-bed psychiatric hospital offering child, adolescent, adult and military service behavioral health programs and treatment services. For more information, please visit us at www.gulfportbehavioral.com/ Position Summary: ** $5000 Sign On Bonus ** Excellent opportunity to join our Senior Leadership Team as a Utilization Review Manager . Will assume responsibility for the functioning of the Utilization Review Department and provide utilization review services in a manner consistent with the philosophy and objectives of the facility; evaluates patient medical records to determine severity of patient’s illness and determines the appropriateness of level of care. Serves as liaison for patients and hospital with insurance companies. Negotiates and advocates for patient length of stay and level of care. Oversees utilization review activities with other departments to ensure reimbursement for services provided by the hospital. Qualifications Education: Bachelor degree in Nursing or Master’s Degree in human services field preferred. Experience: Minimum of 2 years clinical experience and 1 year of management experience with case management and the utilization review process including concurrent reviews. Previous continuum of care experience highly preferred. Licensure: Current license in the state of Missisippi, including RN, LMSW, LMFT, LPC WHAT DO OUR CURRENT EMPLOYEES VALUE AT GULFPORT BEHAVIORAL HEALTH AND UHS? An environment that puts patient care first. One of the most rewarding aspects of this job is providing excellent care, comfort, and security to the patients and families you treat, at their most vulnerable times. Supportive and responsive leadership. You are never alone, as you are part of a large network of peer co-workers that routinely exchange ideas and review current topics within the industry. Having the opportunity to grow, learn, and advance in your career. There are very robust continuing education options and opportunities for skills diversification and career advancement with UHS. BENEFIT HIGHLIGHTS: Challenging and rewarding work environment Career development opportunities within UHS and its Subsidiaries Competitive Compensation Excellent Medical, Dental, Vision and Prescription Drug Plan 401(K) with company match and discounted stock plan Generous Paid Time Off Free Basic Life Insurance Tuition Reimbursement For more information, contact: Cynthia Render-Leach, Human Resources Director at 228-236-2129 or Cynthia.Render-Leach@uhsinc.com . About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance. Growing steadily since our inception into an esteemed Fortune 300 corporation, our annual revenues during 2024 were approximately $15.8 billion. UHS was again recognized as one of the World’s Most Admired Companies by Fortune; ranked #299 on the Fortune 500; and ranked #399 among U.S. companies on Forbes Global 2000 World’s Largest Public Companies. Our operating philosophy is as effective today as it was upon the Company’s founding in 1979, enabling us to provide compassionate care to our patients and their loved ones. Our strategy includes building or acquiring high-quality hospitals in rapidly growing markets, investing in the people and equipment needed to allow each facility to thrive, and becoming the leading healthcare provider in each community we serve. Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and through its subsidiaries operates 28 inpatient acute care hospitals, 331 inpatient behavioral health facilities, 60 outpatient and other facilities, an insurance offering, a physician network and various related services located in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. It acts as the advisor to Universal Health Realty Income Trust, a real estate investment trust (NYSE:UHT). For additional information visit www.uhs.com. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

RN Quality Review Manager- Registered Nurse

Personal Touch Home Aides of New York New York, NY

RN Quality Review Manager- Registered Nurse Brooklyn, NY This a full time , in-person position based out of Brooklyn, NY . RN new grads are welcome . Pay: $90, 000- $105, 000/ annually About Us : With over 50 years of dedicated service to our communities, Personal Touch has been a trusted provider of home care. Our priority lies in ensuring exemplary patient care while fostering a supportive and empowering workplace culture for all team members. We are currently seeking compassionate and skilled nurses to join our team and continue our legacy of providing personalized and attentive care to patients in the comfort of their own home. Why Choose Us: At Personal-Touch Home Care, we are committed to creating a rewarding and fulfilling experience for our team members. Our established history and reputation provide a stable and trusted foundation for your career. Join us in positively impacting the lives of our patients and their families. As a member of our team, you will enjoy a wide range of benefits that enhance your overall well-being and support your career growth. They include: Employee Recognition Programs: We acknowledge and celebrate your contributions. Comprehensive Health Benefits: We offer an inclusive package with Medical, Dental, Vision, Accident, and Long-Term Disability Coverage to ensure access to quality medical care while promoting overall wellness. Generous Paid Time Off: We provide generous paid time off to ensure you can recharge and return to work refreshed, leading to greater productivity and job satisfaction. We support a healthy work-life balance. Retirement Benefits: We offer a 401k plan to secure your financial future and help you save for retirement. Life Insurance: We offer company paid life insurance providing peace of mind and financial protection for you and your loved ones. Mileage Reimbursement: We make sure you're compensated for your business travel. Opportunities for Professional Growth and Development: Empowering you to thrive and grow. Employee Assistance Program: Supporting the well-being of you and your family. Perks Program: Exclusive deals and offers on products, services, and experiences you need and love Job Details Overview: As a RN Clinical Manager/ Quality Review Manager , you will play a pivotal role in coordinating and managing patient care to ensure the highest standards are met. This position involves supervising clinical personnel and ensuring the delivery of quality home care services. Responsibilities: Receive case referrals and assess patient needs to assign appropriate clinicians. Review and evaluate each case, providing guidance to clinicians for effective performance. Instruct and guide clinicians to promote quality care delivery, being available to assist as needed. Review patient clinical information, including diagnosis, medications, and procedures. Assist in establishing therapeutic goals and developing care plans. Attend case conference meetings to facilitate care coordination. Conduct concurrent chart and record reviews and communicate findings to appropriate personnel. Assist in screening, interviewing, and orienting new personnel. Assist in planning and implementing in-service and continuing education programs. Contribute to the formulation, revision, and implementation of policies and procedures. Perform direct patient care duties as needed. Maintain compliance with professional standards and principles. Performs all other duties as assigned. Qualifications: Registered Nurse (RN) with current licensure to practice professional nursing in the State. Graduate of an accredited nursing school; BSN degree preferred. Two (2) years of prior home health care experience. At least one (1) year of management or supervisory experience in a health care setting, preferably home care. Demonstrates excellent observation, verbal and written communication skills. Verbal and written communication skills in English. Job type: Full-time Pay: $90, 000- $105, 000/ annually We are excited to welcome passionate and dedicated individuals to join our team at Personal Touch Home Care . We’re more than just a company, we’re a close-knit family dedicated to supporting each other’s success and well-being. Apply now and join us in making a positive impact on the communities we serve.

Coordinator Peer Review (Registered Nurse)

Southeast Georgia Health System Brunswick, GA

Interested in working for the Golden Isles’ healthcare provider and employer of choice? Throughout the many locations that make up the Southeast Georgia Health System network, there is a common thread that pulls everything together: A team of committed professionals like you. These individuals appreciate the value of every person who walks through our doors and are the key to our culture of Service Excellence. Summary: Manages the Medical Staff Peer Review Process for the Health System by identifying records, review, and analysis of information obtained, summarizing findings, and coordination of provider review. Maintains the integrity, confidentiality, and privilege of the safety event reporting system and Peer Review Professional Practice Evaluation Process. Conducts thorough research, interviews, and retrospective chart reviews on reported safety events and patient/family complaints with provider involvement contributing to the event and/or complaint as appropriate. Coordinates Peer Review meetings to include documentation and follow-up recommendations. Drafts and submits educational and informative decision letters to providers as required and oversees management of Peer Review files. Attends medical staff meetings to integrate medical staff into Performance Improvement Program and advise medical staff on policies and procedures as needed. Adheres to credentialing and peer review deadlines. Processes Peer Review issues in a timely manner. Assists in identifying and coordinating resolution of system process issues that may adversely affect the quality and safety of care being provided to patients. Collaborates with the Risk Analyst on event management through use of the event reporting software, assigning event investigations to appropriate leadership for review and follow-up, ensuring follow-up is timely and complete. Closes the event submission upon completion. Follow up with team members and/or complainants when appropriate. Prepares Risk Reviews as directed. Other job duties pertaining to the functions of the Medical Staff Services Department and Risk Management Department. Minimum Qualifications: Graduate of a Diploma, Associate’s Degree or Bachelor’s Degree Nursing Program Current RN license to practice in the State of Georgia Knowledge of basic nursing theory and practice, medical terminology, and familiarity with Health System policies and procedures. Familiarity with hospital regulatory requirements. Possesses knowledge of Microsoft and Cerner applications. Possess excellent written, oral, and interpersonal communication skills; Strong analytical, problem solving, decision making, and organizational skills Able to establish and maintain effective rapport with members of the medical staff. Able to work in a high volume, complex environment while maintaining confidentiality Able to work independently and able to be a part of a collaborative team. Able to multi-task, create and present data as needed. Why Choose Southeast Georgia Health System? We are mission-focused to provide safe, quality, accessible, and cost-effective care to meet the health needs of the people and communities it serves. Our workplace is as pleasant and rewarding as the setting we enjoy outside of work -- imagine stepping out of your workspace and into a world of scenic beauty, outdoor recreational activities, mild winters, natural beaches, fine dining, and a full array of cultural and colonial historic attractions. The chance to work within a culture that is collegial yet professional, has exceptional career-advancement potential, and work/life balance that is practically unparalleled. Our facility will allow you to use, sharpen, and add to your skills without having to commute to a large city environment. We offer competitive salaries and a comprehensive benefits package which includes generous Paid Time Off, tuition reimbursement, and wellness programs. The ability to be a part of the prestigious Coastal Community Health, a regional affiliation between Baptist Health and Southeast Georgia Health System. This collaboration forms a highly integrated hospital network focused on significant initiatives designed to enhance the quality and value of care provided to our contiguous communities.

Clinical Program Manager-RN (Utilization Management)

Samaritan Health Services Corvallis, OR

Summary Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together. This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin Occasionally JOB SUMMARY/PURPOSE The Clinical Program Manager RN serves as the cornerstone of SHP’s regulatory infrastructure within the utilization management department. This role is responsible for the development, testing, and validation of complex report queries that support federal and state regulatory deliverables. It also oversees the creation and maintenance of policies, procedures, work instructions, and audit tools, while ensuring staff are adequately trained on these materials. The Clinical Program Manager leads all aspects of program development and execution, collaborates with internal teams and external partners, and serves as a subject matter expert across the organization. The position will also oversee and partner other health plan functions such non-emergency medical transport and delegation audits. EXPERIENCE/EDUCATION/QUALIFICATIONS Current unencumbered Oregon RN License required within 90 days of hire. BSN preferred. Master's degree in a related field preferred. One (1) year clinical nursing experience plus four (4) years health plan, case management and/or utilization management experience required. Experience or training in the following required: Health care delivery systems and/or managed care patients. Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced). Experience in the following preferred: Team leadership. Case management. Medicare and Medicaid rules and regulations and health plan benefit structure and policy. KNOWLEDGE/SKILLS/ABILITIES Leadership - Inspires, motivates, and guides others toward accomplishing goals. Achieves desired results through effective people management. Conflict resolution - Influences others to build consensus and gain cooperation. Proactively resolves conflicts in a positive and constructive manner. Critical thinking - Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions. Communication and team building - Lead effectively with excellent verbal and written communication. Delegates and initiates/manage cross-functional teams and multi-disciplinary projects. PHYSICAL DEMANDS Rarely (1 - 10% of the time) (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 - 100% of the time) CLIMB - STAIRS LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs LIFT (Knee to chest: 24"-54") 0 - 20 Lbs LIFT (Waist to Eye: up to 54") 0 - 20 Lbs CARRY 1-handed, 0 - 20 pounds BEND FORWARD at waist KNEEL (on knees) STAND WALK - LEVEL SURFACE ROTATE TRUNK Standing REACH - Upward PUSH (0 - 20 pounds force) PULL (0 - 20 pounds force) SIT CARRY 2-handed, 0 - 20 pounds ROTATE TRUNK Sitting REACH - Forward MANUAL DEXTERITY Hands/wrists FINGER DEXTERITY PINCH Fingers GRASP Hand/Fist