Utilization Review Nurse (Remote- Maine RN Only)

Summary

We are seeking a skilled Utilization Review Nurse to conduct prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines. This involves reviewing medical documentation, accurately documenting findings, and ensuring policy compliance.

Your role in our mission

Review admissions, procedures, services, and supplies for medical necessity and appropriateness, meeting quality and production goals.

Use clinical criteria for decision-making, referring complex cases to Medical Directors when needed.

Engage with providers to gather clinical information, apply guidelines, and make determinations.

Document findings and rationale in medical management systems.

Assist in training new nurses, provide feedback, and stay updated on clinical guidelines.

Maintain RN license and meet continuing education requirements.

What we're looking for

Active Maine RN license.

3+ years of inpatient clinical experience.

1+ year in prior authorization reviews using InterQual.

Strong written communication skills in a fast-paced setting.

Proficient in Microsoft Office and other computer applications.

What you should expect in this role

Home-based position within Maine.

High-speed internet and a distraction-free workspace required.

Core hours : 8 : 00 AM - 6 : 00 PM ET, with potential for extended hours.

Occasional travel (up to 10%) based on business needs.

LI-AC1

LI-REMOTE

This position is for pipeline purposes, and we welcome applications on an ongoing basis.

The pay range for this position is $49,200 - $70,300 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 , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.