Nurse Reviewer Appeals and Hearing

Location:

Any city, OH, US, 99999

Work Mode:
Virtual (Exception only)

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.

We are seeking a talented individual for a Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings.

• Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.
• Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
• Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
• Assist 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.

• Active, unrestricted RN license in the United States and, if applicable, an active multistate RN license under the Nurse Licensure Compact (NLC).
• 5+ years of clinical experience or medical record coding experience.
• 3+ years of utilization review or claims auditing experience, with working knowledge of the appeals and hearings process.
• Experience applying clinical review criteria, with MCG or Inter Qual experience preferred.
• Strong written and verbal communication skills, including the ability to develop clear, fact-based appeal rationales, present case summaries and decisions, and manage multiple priorities in a fast-paced environment

• Remote (Work from Home)
• Up to 25% Travel for onsite hearing testimony
• The deadline to submit applications for this posting is December 31, 2026.

The pay range for this position is 69,400.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…