Medical Reviewer (Registered Nurse) - Remote CA

$70,000 - $100,000 / year

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 Gainwell Technologies is seeking a Medical Reviewer (Registered Nurse) to support Medical Review Services for California healthcare programs. In this role, you will use your professional nursing experience and clinical judgment to review medical records, healthcare services, claims, and authorization requests.Your role in our mission Review and interpret medical records and clinical documentation to determine medical necessity and appropriateness of healthcare services. Provide clinical review support for Treatment Authorization Requests (TARs) and other authorization activities. Support medical review activities related to medical policy, claim adjudication, drug utilization review, and other healthcare program requirements as assigned. Apply professional nursing principles, clinical judgment, medical policies, and established utilization guidelines when completing reviews. Review medical documentation to determine whether requested services, procedures, supplies, and equipment meet applicable coverage and clinical requirements. Document review findings, decisions, and supporting clinical rationale accurately and timely. Determine approvals within established guidelines or refer cases to physicians or other appropriate clinical professionals when additional review is required. Apply knowledge of hospital routines, medical services, medical supplies, and their appropriate clinical uses when conducting reviews. Collaborate with physicians, pharmacists, nurses, and other healthcare professionals to support accurate medical review determinations. Maintain current knowledge of applicable clinical criteria, medical policies, procedures, and regulatory requirements. Meet established quality, accuracy, and productivity standards. What we're looking for Active and unrestricted Registered Nurse (RN) license to practice in the State of California, in good standing. Minimum of two (2) years of professional nursing experience. Possession of a Master’s Degree in Nursing may substitute for one (1) year of the required professional nursing experience. Knowledge of professional nursing principles and techniques, hospital routines, and medical supplies and their uses. Training and/or certification in wound and ostomy care preferred. Strong clinical judgment and ability to interpret medical records and supporting clinical documentation. Experience with medical review, utilization review, medical necessity review, prior authorization, Treatment Authorization Requests (TARs), or claims review preferred. Strong written and verbal communication skills. What you should expect in this role Full-time position. Remote work environment. Monday through Friday work schedule. Work primarily from your home office while supporting Medical Review Services for California healthcare programs. Spend the majority of your day reviewing medical, clinical, claim, authorization, and/or supporting documentation relevant to your area of expertise. Work independently while collaborating with physicians, pharmacists, nurses, other clinical specialists, operations teams, and business partners. Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations. Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status, as applicable. Maintain knowledge of applicable medical policies, coverage requirements, clinical standards, and regulatory guidelines. Meet established quality, accuracy, productivity, and turnaround-time expectations. Receive ongoing training and support related to program requirements, systems, policies, and medical review processes. This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis. #LI-REMOTE #LI-MA1 The pay range for this position is $70,000 - $100,000 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 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. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.

Share this job

Related Jobs

Utilization Review Nurse- Remote

Gainwell Technologies LLC Arkansas City, AR

$65,000 - $78,000 / year

DRG Nurse Reviewer Appeals and Hearings- Remote

Gainwell Technologies LLC Tampa, FL

$90,000 - $99,000 / year

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 DRG 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. Your role in our mission 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. 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. What we're looking for Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required 5+ years clinical experience or 5+ years medical record coding experience preferred Working knowledge of the appeals and hearings process Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What you should expect in this role Remote (Work from Home) Up to 25% Travel for onsite hearing testimony This position is for pipeline purposes, and we welcome applications on an ongoing basis. The pay range for this position is $90,000.00 - $99,000.00 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 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.

Telehealth

Full-time

13 hours ago

RN Call Center, Clinical Access

Summa Health Cleveland, OH

$35.09 - $42.11 / hour

RN Call Center, Full-Time 9:00am-7:30pm, 10hr e/o weekend-holiday Clinical Access Center Potential opportunity to work from home after successful completion of on-site training** Summa Health System is recognized as one of the region’s top employers by a number of third party organizations, including NorthCoast 99. Exceptional candidates gravitate to Summa because of its culture, passion for delivering excellent service to our patients and families commitment to our philosophy of servant leadership, collegial working relationships at every level of the organization and competitive pay and benefits. Summary Responsible to drive Population Health through clinical access and communication in a call center environment. They are the first voice of Summa Health that patients, physicians, and hospital faculty will encounter when communicating the organization. This role has the critical responsibility of providing all patients and physicians unparalleled experience and support in the following capacities; interacting with patients virtually to assess their clinical needs and requirements to achieve and/or maintain their health, evaluation of patient medical concerns, initial screening of patient signs and symptoms, acts in collaboration with the physician’s care team, collaboration with the multi-disciplinary team, guides members toward and facilitate interaction with resources appropriate for care and well-being, utilizing recourses available to uphold the population healthcare model, and any other questions or concerns. Minimum Qualifications Formal Education Required: Associate’s degree in Nursing (ADN) required, BSN preferred Graduate of a program of professional nursing that is accredited by the Commission on Collegiate Nursing Education (CCNE) or Accreditation Commission for Education in Nursing (ACEN) Current RN License to Practice Nursing in the State of Ohio Experience and Training Required: Three (3) years recent clinical experience in a physician office, home health, critical care and/or emergency room. OR Two (2) years recent critical care clinical experience with previous clinical experience. Relevant critical care experience includes: work as a direct patient care nurse in an emergency room, intensive care unit, or coronary care unit. Relevant previous clinical experience: work as a patient care technician or similar in an emergency room, intensive care unit, or coronary care unit. Relevant experience includes: direct patient triage, clinical phone triage, demonstrated excellence in clinical assessment using the nursing process, or adult/pediatric nursing care in a physician or hospital setting. Knowledge of keyboard with extreme accuracy and Microsoft Office products (Excel, Word, Outlook). Other Skills, Competencies and Qualifications: Population Specific Competency: Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity. Customer Focus Adaptability and flexibility Ability to understand and follow directions Ability to multitask using the computer and interacting with patients/physicians virtually Communication Professionalism, Enthusiasm, and Positivity Integrity/ethical standards Results-oriented Organizational skills with a strong attention to detail Personal leadership skills Conflict resolution Influence when speaking with others Strong critical thinking Basic Life Support (BLS) certification Level of Physical Demands: Sedentary: Exerts up to ten pounds of force occasionally and/or a negligible amount of force frequently. Ability to sit for extended periods of time Work weekends, evenings, and holidays as assigned Reliable Transportation required Ability to adjust work hours to meet business demands as required Equal Opportunity Employer/Veterans/Disabled $35.09/hr - $42.11/hr The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical. Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits. Basic Life and Accidental Death & Dismemberment (AD&D) Supplemental Life and AD&D Dependent Life Insurance Short-Term and Long-Term Disability Accident Insurance, Hospital Indemnity, and Critical Illness Retirement Savings Plan Flexible Spending Accounts – Healthcare and Dependent Care Employee Assistance Program (EAP) Identity Theft Protection Pet Insurance Education Assistance Daily Pay

Telehealth

Full-time

1 day ago

Registered Nurse

Oak Street Health International District, NM

$60,522 - $129,615 / year

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Title: Registered Nurse Company: Oak Street Health Role Description: The purpose of a Registered Nurse at Oak Street Health is to build strong relationships with Oak Street Health patients by coordinating their care and providing a seamless experience to patients and their support team. At Oak Street Health you will use an integrated approach toward achieving desired patient outcomes by utilizing standards, guidelines and pathways for care delivery. Through clinical assessment, intervention and education you will ensure our patients are provided competent nursing care in a timely manner. Our Registered Nurses drive quality care, it is of vital importance that our nurses incorporate data and information to improve care and enhance our patient outcomes. You will work to create an engaging and welcoming environment through team communication and delegation to empower other members of the care team to deliver the best care to our patients. Our Registered Nurses report to the Practice Manager or Nurse Supervisor (where applicable). Core Responsibilities: Provide competent nursing care by displaying proficiency in this role and executing job responsibilities in a safe and consistent manner Respond to incoming telephonic requests in a dependable manner, ensuring we are responsive to their needs and exceeding expectations Provide clinically competent triage and symptom management to patients who may or may not be physically present Utilize standardized protocols for medication management, prescription refills and prior authorizations. Conduct thorough and accurate reviews of patient medications and update as needed Provide comprehensive education and direct patient care, particularly around chronic conditions; may occur in person, over the phone or in group settings Actively collaborate and monitor the implementation and progress of the care plan for patients on multiple provider panels Form relationships with patients and their caregivers to support preventative care and ED/hospital diversion where appropriate Create a welcoming and engaging environment to meet the needs of our patients, communities, families and teams where they are Delegation of activities to other clinical care team members to support the needs of our patients Participate in care team meetings to discuss patient care and clinic operations Deliver an exceptional patient experience through service, responsiveness and respectful care Perform point of care testing, procedures and specimen collection (including phlebotomy) as needed Performs other related duties as assigned What we're looking for Required Qualifications: Active Registered Nurse (RN) Licensure in good standing with the applicable state BLS Certification Electronic Medical Record (EMR) experience Ability to maintain patient confidentiality and process information in a confidential manner US work authorization Ability to assess patients without face-to face interaction, strong communication and assessment skill Strongly Preferred Qualifications: Ability to collaborate and communicate with members of an interdisciplinary care team Excellent computer skills with ability to read, interpret and analyze data from various computer systems Effective problem solving and prioritization skills 2+ years of healthcare experience, working as an RN Preferred Qualifications: Previous experience in clinic setting Ability to work independently Fluency in Spanish, Polish, Russian, or other languages spoken by people in the communities we serve Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $60,522.00 - $129,615.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments . We anticipate the application window for this opening will close on: 12/06/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Telehealth

Full-time

1 day ago

Registered Nurse (RN) - Virtual Care Network

Texas Children's Hospital Houston, TX

Job Description At Texas Children’s Hospital, our mission starts with our people. Guided by our HEART values—Humility, Excellence, Accountability, Respect, and Trust—we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day. Texas Children’s Virtual Care Network is seeking experienced, innovative nurses who are passionate about patient- and family-centered care and excited to help transform how nursing care is delivered. Virtual Nurses partner with bedside nurses to provide admission support, patient and family education, discharge readiness, and discharge teaching through technology-enabled care model. This role is ideal for nurses who are strong communicators, educators, collaborators, and critical thinkers and who are comfortable using technology to support patients, families, and bedside care teams. As a Virtual Nurse, you remain an essential part of the nursing care team while helping create additional capacity for bedside nurses to focus on direct patient care. This position is onsite at our Meyer Building, and schedule will be 1230p-9pm (8hr shifts that will including rotating individual weekend shifts) Responsibilities Performs and documents assessment of the patient/family including biophysical, psychosocial, developmental (age-appropriate), culture, spiritual, and environmental needs in an organized and systematic manner Analyzes situations, anticipates potential problems, and detects changes in patient status. Re-prioritizes and updates plan of care based on new information and changes to the patient’s condition; communicates this information to other health care team members and documents in the medical record. Participates in interdisciplinary rounds and/or patient care conferences and documents in the medical record. Assists patients/family in implementing their role in the plan of care as appropriate. Assess patient family learning needs capabilities, preferences, and readiness to learn prior to teaching. Demonstrates positive and effective interpersonal skills when dealing with patients/families, visitors, peers, and other health care team members. Administers and documents medications and treatments in a timely manner. Demonstrates willingness and ability to acquire new knowledge and utilize new skills needed to improve individual, team, and organizational performance. Participate in unit performance improvement initiatives Qualifications Bachelor's degree in nursing or other degree in nursing with acceptance or current enrollment in a BSN program and signed agreement Current licensure with the Board of Nursing for the State of Texas or Nurse Licensure Compact Current BLS certification from the American Heart Association 9 months of professional nursing experience Preferred Qualifications 2yrs of nursing experience Acute Care experience and ability to cross-train to cover NICU and Mother/ Baby Proficiency with EPIC (or comparable electronic health record systems) Ability to conduct virtual patient intakes and provide patient education via phone or digital platforms Strong clinical judgment and critical-thinking skills Excellent communication and patient/family education skills Demonstrated ability to collaborate with interdisciplinary teams Comfortable with technology and virtual care delivery Strong organization and time-management skills Adaptable and innovative, with the ability to navigate changing workflows Commitment to patient- and family-centered care As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards. About Us Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S. News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years. Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Tower for pediatric research; Texas Children ’ s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children ’ s Hospital West Campus, a community hospital in suburban West Houston; Texas Children ’ s Hospital The Woodlands, the first hospital devoted to children ’ s care for communities north of Houston; and Texas Children’s Hospital North Austin, the new state-of-the-art facility providing world-class pediatric and maternal care to Austin and Central Texas families. We have also created Texas Children ’ s Health Plan, the nation ’ s first HMO focused on children; Texas Children ’ s Pediatrics, the largest pediatric primary care network in the country; Texas Children ’ s Urgent Care clinics that specialize in after-hours care tailored specifically for children; and a global health program that is channeling care to children and women all over the world. Texas Children ’ s Hospital is affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation. To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.