Medical Reviewer, Registered Nurse

Gainwell Technologies

Medical Reviewer (Registered Nurse) reviewing California healthcare records, claims, and authorizations for Gainwell Technologies. Determining medical necessity and supporting healthcare program compliance remotely.

Posted 8/22/2026full-timeRemote • California • 🇺🇸 United StatesJuniorMid-Level💰 $70,000 - $100,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical review processes, including medical necessity and appropriateness assessments, while applying professional nursing principles and maintaining compliance with medical policies and regulatory requirements. Proficient in navigating multiple systems to document findings and collaborate effectively with healthcare professionals.

Highest-signal resume keywords

Registered Nurse (RN) LicenseClinical Review SupportMedical Necessity ReviewStrong Clinical JudgmentTreatment Authorization Requests (TARs)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewUtilization ReviewClaims ReviewDocumentation AccuracyClinical Policy Application

Soft Skills

Strong Written CommunicationStrong Verbal CommunicationCollaboration with Healthcare Professionals

Tools & Technologies

Multiple Computer SystemsHealthcare Applications

Certifications & Qualifications

Wound and Ostomy Care Certification (Preferred)

Industry Keywords

Healthcare ServicesMedical PoliciesClinical DocumentationRegulatory RequirementsCalifornia Healthcare Programs

About the role

Key responsibilities & impact

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
Apply professional nursing principles, clinical judgment, medical policies, and established utilization guidelines when completing reviews
Review documentation to determine whether requested services, procedures, supplies, and equipment meet 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
Apply knowledge of hospital routines, medical services, medical supplies, and appropriate clinical uses
Collaborate with physicians, pharmacists, nurses, and other healthcare professionals
Maintain current knowledge of clinical criteria, medical policies, procedures, and regulatory requirements
Meet established quality, accuracy, productivity, and turnaround-time standards
Work primarily from a home office supporting Medical Review Services for California healthcare programs
Navigate multiple systems and applications to complete reviews and document findings

Requirements

What you’ll need

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
Ability to navigate multiple computer systems and applications
Ability to maintain required professional licenses, certifications, and credentials in active, unrestricted, and good-standing status

Benefits

Comp & perks

Flexible hours
Work-life balance
Continuous learning and career development
Flexible vacation policy
401(k) employer match
Comprehensive health benefits
Educational assistance
Leadership and technical development academies
Ongoing training and support