Nurse Reviewer Appeals and Hearing

$69,400 - $99,200 / 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 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. 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. What we're looking for 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 InterQual 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 What you should expect in this role 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 69,400.00 - 99,200.00 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. 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.

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Medical Reviewer (Registered Nurse) - Remote CA

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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. 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DRG Nurse Reviewer Appeals and Hearings- Remote

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$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.

Utilization Management Nurse RN

Personify Health Remote, OR

$35 - $38 / hour

Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Ready to make the right call on care, fast, fairly, and by the book? Why This Role Matters Every day, members and providers are waiting on a decision that shapes what care happens next. As a Utilization Management Nurse, you’re the clinical expert who gets it right. You’ll review requests against plan language, medical policies, and evidence-based criteria, then deliver timely, compliant determinations that protect both member access and appropriate use of resources. When a case needs a deeper look, you’ll route it to the Medical Director and support appeals with clear, complete clinical summaries. Your documentation keeps us audit-ready under NCQA and URAC standards. When you deliver accurate, on-time decisions, members get the care they need and the organization earns the trust that keeps our programs strong. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You’ll Actually Do Decide with clinical rigor: Perform medical-necessity reviews and level-of-care determinations using benefit language, plan documents, medical policies, and nationally recognized evidence-based criteria such as MCG (and NCCN as applicable), in line with state and federal requirements. 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Power the appeals process: Prepare clinical summaries and supporting documentation, coordinate peer-to-peer and Medical Director discussions when indicated, and route cases on time per policy, including Independent Review Organization (IRO) processes when required. Document with precision: Record reviews, rationale, criteria and policy citations, communications, and outcomes accurately and in real time in designated UM systems to support quality oversight, reporting, and audit readiness. Hit the standard: Meet productivity, quality, accuracy, and turnaround-time expectations, take part in calibration and quality activities, and put feedback to work in your daily practice. Protect member privacy: Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and complete required training and annual competencies by their deadlines. Back up the team: Cross-train and provide cross-coverage to keep operations running and service-level commitments met. Qualifications: What You Bring to Our Team Education & Experience: Current, unrestricted RN license in the United States or a U.S. territory (compact license acceptable where applicable) Graduate of an accredited nursing program (ADN or diploma required; BSN preferred) Minimum 1–2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting Prior utilization review or utilization management experience preferred Technical Skills: Ability to interpret medical records and apply evidence-based criteria and plan medical policies, with appropriate escalation to the Medical Director for non-certifications Working knowledge of MCG, NCCN (as applicable), NCQA and URAC standards, and HIPAA requirements Knowledge of medical claims and ICD-10, CPT, and HCPCS coding Proficiency in Microsoft Word, Excel, and Outlook Basic computer literacy, proficient typing, and the ability to work across multiple screens Ability to work independently within UM systems and programs after training Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $35.00-$38.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .

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Case Management Nurse RN

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Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Ready to turn complex medical journeys into clear plans and better outcomes? Why This Role Matters When a member faces a serious diagnosis or a difficult recovery, they need someone in their corner who knows the system and can make it work for them. That’s you. As a Case Manager, you’ll assess the whole person, build care plans that fit their life, and connect them with the providers and programs that move them forward. Your clinical judgment improves outcomes while ensuring care is used appropriately and costs stay in check. You’ll also guide LVNs and LPNs on complex cases and set the standard for documentation and compliance. When you do this well, members get better care and the organization earns the trust that keeps our programs strong. What You’ll Actually Do Manage cases by phone: Lead short- and long-term cases in line with company guidelines, policies, and industry criteria (NCQA, CMSA, URAC), keeping members moving toward their goals. Assess the whole person: Conduct comprehensive biopsychosocial assessments covering physical, emotional, psychosocial, spiritual, environmental, and financial factors so every care decision starts with the full picture. Find the story in the claims: Use claims-processing tools to review paid claims, identify health trends, and determine eligibility for case management programs. Build and refine care plans: Develop and update individualized treatment plans for standard and catastrophic cases with measurable short- and long-term goals. Prove the impact: Evaluate intervention effectiveness and document measurable outcomes that show clinical impact and cost savings. Keep everyone connected: Maintain continuous communication with members, caregivers, providers, employers, and the multidisciplinary team throughout the course of care. Advocate for quality and value: Champion quality patient care while supporting appropriate utilization and reducing overall healthcare costs, and refer members to chronic disease, wellness, behavioral health, and vendor-specific programs as needed. Drive cost management: Implement cost management strategies and document results in case management reviews and cost-avoidance reporting. Support utilization review: Assist with Utilization Review for assigned members to keep care appropriate and well coordinated. Mentor and guide: Coach LVNs and LPNs and support complex case guidance within licensure scope. Set the compliance standard: Serve as a subject-matter expert in NCQA, URAC, and CMSA standards and documentation best practices, maintain compliance with CMS and other regulatory audit standards, and keep accurate, confidential records per company policy and HIPAA. Deliver every day: Meet daily, weekly, and monthly productivity, quality, and turnaround standards, and complete required annual education and competencies. This job description is not an exclusive or exhaustive list of all job functions that an employee in this position may be asked to perform. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs Qualifications: What You Bring to Our Team Education & Experience: Graduate of an accredited nursing program Current RN license required based on business need 3 years of medical/surgical or acute care experience Technical Skills: Working knowledge of NCQA, URAC, CMSA, and CMS standards and HIPAA requirements Knowledge of medical claims and ICD-10, CPT, and HCPCS coding Proficiency in Microsoft Word, Excel, and Outlook Basic computer literacy, proficient typing, and the ability to work across multiple screens Proficiency in Teams (on and off camera), SharePoint, shared drives, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Smartsheet, and a phone system with headset; additional programs may apply based on job duties Full system proficiency expected after training and a 1.5-month ramp (3 months total) Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $35.00-$37.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .