Utilization Review Nurse (Remote- Maine RN Only)

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 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.

• 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.

• Active Maine RN license.

• 3+ years of inpatient clinical experience.

• 1+ year in prior authorization reviews using InterQual.

• Strong written communication skills in a fast-paced setting.

• Proficient in Microsoft Office and other computer applications.

• Home-based position within Maine.

• 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.

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This position is for pipeline purposes, and we welcome applications on an ongoing basis.

The pay range for this position is $49,200- $70,300 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 committed to a diverse, equitable, and inclusive workplace. We are proud to be 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), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.