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Utilization Review Nurse (Remote- Maine RN Only) ID-21255

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.

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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 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.

What you should expect in this role

  • 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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