Gainwell TechnologiesGT

Senior Professional Nurse- Remote

Gainwell Technologies is a healthcare technology company that provides digitally enabled services and solutions for health and human services programs, focusing on improving outcomes for vulnerable populations.

Gainwell Technologies

Employee count: 5000+

Salary: 64k-80k USD

United States only

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.

Job Duties:

  • Conduct objective desk and medical record audits to verify service documentation, determine appropriate administration, and validate coding/billing accuracy.

  • Interview providers and health plan members to assess potential fraud, waste, or abuse.

  • Collaborate with internal teams (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to collect relevant documentation for investigations.

  • Identify potential healthcare fraud, waste, and abuse by analyzing aberrant coding and billing patterns through utilization review.

  • Communicate effectively with physicians and healthcare professionals during investigations.

  • Prepare accurate and timely reports detailing audit findings for internal and external stakeholders.

  • Provide provider education on best practices (e.g., coding) based on national/local guidelines, contractual obligations, and regulatory requirements.

  • Identify process improvement opportunities and recommend system enhancements to optimize investigative outcomes and performance.

Job Qualifications:

  • Graduate from an accredited School of Nursing.

Required Experience, Knowledge, Skills & Abilities:

  • Minimum of five years of clinical nursing experience with broad clinical knowledge.

  • At least five years of experience in medical review and coding/billing audits for both professional and facility-based services.

  • Strong understanding of medical terminology, CPT, ICD-9/10, HCPCS, and DRG coding requirements.

  • Minimum two years of managed care experience.

Required License, Certification & Associations:

  • Active, unrestricted RN license in good standing.

  • Preferred: Bachelor’s Degree in Nursing.

  • Experience with government healthcare programs (Medicare, Medicaid, SCHIP).

  • Experience in long-term care preferred.

Job Details:

Location: 100% Remote within the U.S.

The pay range for this position is $64,000.00 - $80,000.00 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.

About the job

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Job type

Full Time

Experience level

Senior

Salary

Salary: 64k-80k USD

Location requirements

Hiring timezones

United States +/- 0 hours

About Gainwell Technologies

Learn more about Gainwell Technologies and their company culture.

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At Gainwell Technologies, we are at the forefront of pioneering advancements in health and human services. Through groundbreaking technology, we are revolutionizing how public sector agencies and commercial health plans operate and deliver care to millions. Our innovative solutions are designed to enhance outcomes, improve efficiency, and ensure the integrity of vital healthcare programs. We harness the power of data analytics, cloud-based platforms, and digital tools to create a more connected and responsive healthcare ecosystem. Our commitment to innovation is unwavering as we develop and implement next-generation systems that address the complex challenges facing the healthcare industry today. This includes modernizing Medicaid management systems, developing sophisticated data repositories for public health, and creating AI-powered tools to improve member engagement and provider experiences. We empower our clients with scalable and flexible technologies that not only meet current needs but also anticipate future demands, ensuring they can adapt to the ever-evolving landscape of healthcare.

Gainwell Technologies is dedicated to fostering a culture of innovation where new ideas are encouraged and transformative solutions are born. We invest in research and development to explore emerging technologies like artificial intelligence, machine learning, and blockchain, seeking new ways to drive meaningful improvements in health and human services. Our team of experts collaborates closely with clients to understand their unique challenges and co-create solutions that deliver tangible results. By focusing on technological breakthroughs, we aim to simplify complex processes, improve access to care for vulnerable populations, and ultimately contribute to healthier communities. Our work impacts millions of lives, and we are driven by the mission to make healthcare more efficient, effective, and equitable for everyone. Through continuous innovation and a deep understanding of the health and human services domain, Gainwell Technologies is shaping the future of healthcare technology.

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Gainwell Technologies

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