Utilization Review Nurse

Gainwell Technologies

. Review and evaluate prior authorization requests to determine medical necessity, appropriateness, and cost-effectiveness of services .

Posted 9/21/2026full-timeRemote • United StatesJuniorMid-Level💰 $64,500 - $82,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical assessment, utilization review, and prior authorization processes while ensuring compliance with regulatory guidelines. Strong communication and analytical skills support effective collaboration with healthcare providers and stakeholders.

Highest-signal resume keywords

Active RN Or LPN LicenseUtilization Review ExperiencePrior Authorization ExperienceMedicaid ExperienceClinical Assessment Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical EvaluationRegulatory InterpretationHealthcare Policy DevelopmentCost-Effectiveness AnalysisDecision-MakingCase ManagementHealthcare ComplianceProgram InitiativesAnalytical SkillsOrganizational Skills

Soft Skills

Strong Communication SkillsTime Management SkillsIndependent Work Ability

Tools & Technologies

PC-Based SystemsHealthcare Applications

Certifications & Qualifications

Bachelor's DegreeActive RN Or LPN License

Industry Keywords

HealthcareManaged CareMedicaidPrior AuthorizationUtilization ReviewCase ManagementClinical GuidelinesCost ContainmentProvider CommunicationProgram Requirements

About the role

Key responsibilities & impact

Review and evaluate prior authorization requests to determine medical necessity, appropriateness, and cost-effectiveness of services
Support access to quality care while ensuring compliance with program requirements and clinical guidelines
Serve as a clinical resource for providers, customers, and internal teams by resolving healthcare-related questions and concerns
Collaborate with providers, members, and internal stakeholders to facilitate timely and appropriate healthcare decisions
Interpret and apply complex clinical, regulatory, and procedural guidelines
Support utilization review and case management activities through clinical assessment and decision-making
Assist in developing and improving healthcare policies, provider communications, and program initiatives
Contribute to healthcare cost containment efforts while ensuring appropriate, medically necessary care
Work independently while partnering with cross-functional teams to achieve program goals

Requirements

What you’ll need

Bachelor's degree or equivalent combination of education and experience
Active, unrestricted RN or LPN license in the United States
Strong oral and written communication skills
Strong analytical, organizational, and time management skills
Ability to read, understand, and interpret complex regulatory and procedural documents
Proficiency with PC-based systems and applications
Ability to work independently with minimal supervision
Two or more years of Medicaid experience or other healthcare experience
Previous experience supporting Utilization Review, Prior Authorization, Case Management, or Managed Care programs

Benefits

Comp & perks

Flexible hours
Work-life balance
Continuous learning and career development
100% remote work environment
Flexible vacation policy
401(k) employer match
Comprehensive health benefits
Educational assistance
Leadership and technical development academies