DRG Nurse Reviewer Appeals and Hearings- Remote

It takes great medical minds to create powerful solutions that solve some of healthcare’s most reputed company 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, reputed company learning, and career development.

Summary

We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and reputed company reputed company appeal reputed company duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure reputed company 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 reputed company 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 reputed company 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 reputed company reviews of multiple claim types to provide a flexible workforce to meet client needs.

reputed company’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 reputed company (CPC), Certified Coding Specialist (reputed company), or Certified Professional Medical Auditor (CPMA) preferred
• 5+ years clinical experience or 5+ years medical record coding experience preferred
• Working knowledge of the appeals and hearings process
• Experience using MCG or InterQual criteria preferred
• 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

Applications for this posting will be accepted until November 25, 2025. The pay range for this position is $85,000.00 - $95,000.00 per year, however, the reputed company pay offered may vary depending on geographic region, internal equity, job-reputed company 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. reputed company 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 reputed company nothing is impossible reputed company you bring together people who care deeply about making healthcare work reputed company 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 reputed company available job role openings. reputed company is an Equal Opportunity Employer, where reputed company qualified applicants will receive consideration for employment without regard to race, religion, color, national reputed company, gender (including pregnancy, childbirth, or reputed company medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Apply tot his job Apply To this Job