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 a Clinical Quality Reviewer who is responsible for performing on-going assessments of the quality of work performed by Reviewers. This person is responsible for complex quality reviews to determine if decision by review staff matches medical records and approved review methodologies. This person is also responsible for working closely with the other clinical Supervisors and Managers to ensure that Clinical Reviewers are producing work that meets internal quality standards.

Your Role in Our Mission

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  Perform Quality Assurance checks on final review work during and after the orientation period.
• Review and analyze claim data and synthesize medical record using approved clinical and coding guidelines.
• Document review determination clearly and concisely.
• Provide detail documentation of quality review results for trending and reporting.
• Analyzes and reviews documentation to ensure all aspects of the review have been addressed properly and accurately while maintaining production goals and quality standards.
• Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
• Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
• Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
• Coordinate with, and assist, Project Managers in performing ongoing IQC for all Nurse Reviewers and Project Specialists per department procedures or more often if problems are identified.
• Facilitate the Physician IQC process and communicates/coordinates frequently with the Chief Medical Officer regarding indentified physician learning needs.
• Offers quality improvement suggestions on project protocols and processes; facilitates quality improvement plan in conjunction with Manager.
• Collaborate with Manager, Clinical Quality for identified quality issues.
• Work with Review Supervisor/Sr. Nurse Reviewer/Service Line Manager to facilitate quality improvement plan development and implementation as needed for both internal and external customers.

What We're Looking For

• 
  Perform Quality Assurance checks on final review work during and after the orientation period.

• Review and analyze claim data and synthesize medical record using approved clinical and coding guidelines.
• Document review determination clearly and concisely.
• Provide detail documentation of quality review results for trending and reporting.
• Analyzes and reviews documentation to ensure all aspects of the review have been addressed properly and accurately while maintaining production goals and quality standards.

What You Can Expect in This Role

• 
  Home based position and you must have a work location within the continental US
• This position requires that you provide high speed internet connection and a work environment free from distractions but we provide all needed equipment
• Most benefits start on first day of employment
• Monday through Friday work schedule

#LI-NB1

#LI-REMOTE

The pay range for this position is $75,000.00 - $90,000.00 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 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.