Nurse Reviewer - Itemized Bill Review

Nurse Reviewer - Itemized Bill Review

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- Itemized Bill Review role to perform reviews of medical records, healthcare claims, itemized medical bills, and UB‑04 forms to ensure accuracy, compliance, and proper billing practices. This position requires clinical review expertise as well as experience with itemized bill review.

Your role in our mission: Review medical claims using the UB‑04 and detailed itemized statements to validate line‑item charges. Verify accuracy of itemized charges in accordance with client policy and industry standards. Perform level‑of‑care and utilization reviews by analyzing medical records and comparing them against criteria to determine appropriateness and reasonableness of care. Apply critical thinking and decision‑making skills to determine whether medical record documentation supports the need for services while meeting production goals and quality standards. Assist management with training new reviewers, including daily monitoring, mentoring, feedback, and education. Maintain current knowledge of clinical criteria guidelines and/or coding guidelines; complete required CEUs to maintain RN licensure. Attend training and scheduled meetings to enhance knowledge of clinical policies, procedures, rules, and regulations. Actively cross‑train to perform reviews of multiple claim types to support a flexible workforce that meets client needs.

What we're looking for: Active, unrestricted RN license in the United States and in the primary state of residence; active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) required. 5+ years of clinical experience in an inpatient hospital setting required. 1+ year of itemized bill review experience required. 3+ years of utilization review or claims auditing experience preferred. Experience with CPT, ICD‑10, and HCPCS coding guidelines. Experience using MCG or InterQual criteria preferred. Ability to multitask in a fast‑paced production environment.

What you should expect in this role: This is a home‑based position, and you must have a work location within the continental United States. You must provide a high‑speed internet connection and maintain a work environment free from distractions. Ability to work during normal business hours, as this role requires frequent interaction with the team and other departments. May be required to work extended hours for special business needs. May be required to travel at least 10% of the time based on business needs. The pay range for this position is $78,000.00 - $85,000.00 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.