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Nursing Services Reviewer, Specialist
Gainwell Technologies. Perform clinical reviews to determine whether medical record documentation supports the need for services .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical reviews, utilization review, and claims auditing, with a strong focus on interpreting medical records against established clinical criteria and guidelines. Maintains active RN licensure while providing training and mentorship to new Nurse Reviewers.
Highest-signal resume keywords
Active RN Licensure In MassachusettsUtilization Review ExperienceClaims Auditing ExperienceExperience With Milliman Or InterQual CriteriaClinical Experience In Inpatient Hospital Setting
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewMedical Record InterpretationPrior AuthorizationPrecertificationRetrospective ReviewDocumentation AccuracyProcess ImprovementAudit ConceptsTechnology SolutionsDecision Letter Preparation
Soft Skills
MentoringFeedbackCollaborationFlexibilityCommunication
Tools & Technologies
Microsoft WindowsMicrosoft OutlookMicrosoft ExcelMicrosoft WordMicrosoft PowerPointInternet Browsers
Certifications & Qualifications
Active RN Licensure In MassachusettsCompact Multistate RN License
Industry Keywords
Clinical Criteria GuidelinesUtilization GuidelinesCoverage PoliciesPractice GuidelinesInpatient Hospital Setting
About the role
Key responsibilities & impact- Perform clinical reviews to determine whether medical record documentation supports the need for services
- Review and interpret medical records against clinical criteria, coverage policies, utilization guidelines, and practice guidelines
- Access proprietary systems to audit medical records
- Document findings, decisions, and rationale accurately
- Determine approvals or refer cases to physician consultants
- Process consultant decisions and complete detailed denial reasons within deadlines
- Perform prior authorization, precertification, and retrospective reviews
- Prepare decision letters as required
- Assist management with training new Nurse Reviewers through monitoring, mentoring, feedback, and education
- Maintain knowledge of clinical criteria guidelines and complete CEUs to maintain RN licensure
- Attend trainings and meetings concerning clinical policies, procedures, rules, and regulations
- Cross-train to review multiple claim types
- Recommend and help implement process improvements, audit concepts, and technology solutions
Requirements
What you’ll need- Active, unrestricted RN licensure in Massachusetts required
- Compact multistate RN license strongly preferred
- 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
- Proficient in computer and typing skills
- Proficiency with Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers
- Ability to work standard business hours with frequent interactions across teams and departments
- Flexibility to work extended hours when needed to support business demands
- Must reside within the United States and work from the continental U.S.
- Must maintain an active Massachusetts RN license
- Private, distraction-free work environment without loud noises or recording devices
Benefits
Comp & perks- Health benefits (medical, dental, vision) begin on the first day of employment
- Paid time off begins on the first day of employment
- Full-time, permanent salaried W-2 employee position
- Remote work arrangement
- Standard Monday through Friday work schedule