Utilization Review Nurse- Remote

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.

• 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, unrestricted RN licensure in the U.S. and primary state of residence, plus an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC); verification required during post-offer background check.
• 3+ years of inpatient clinical experience.
• 1+ year in prior authorization reviews using Inter Qual or MCG.
• Strong written communication skills in a fast-paced setting.
• Proficient in Microsoft Office and other computer applications.

• Home-based role available to applicants residing anywhere in the U.S.
• 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.

The pay range for this position is $78,000.00 to $88,000.00 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 ’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 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), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.