Advisor Nurse (Remote in Wisconsin) in Madison, WI

Advisor Nurse (Remote in Wisconsin) – Gainwell Technologies – Madison, WI – work from home job

Company: Gainwell Technologies

Job description: 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

Under the direction of the Nursing Administrator of the Clinical Program Integrity & Compliance Section, this highly responsible professional position must exhibit responsible clinical and professional judgment and act under general supervision.

This position serves as an Office of Inspector General’s Nurse Consultant for pre-payment activities. This position conducts the review of clinical and financial pre-payment compliance review activities in the Office of the Inspector General (“OIG”) to detect, combat, and eliminate fraud, waste and abuse in the Medicaid program. This position also has responsibilities in the areas of consulting on the development and implementation of pre-payment review policies and guidelines designed to promote program and departmental objectives in OIG. This position requires the ability to perform comprehensive medical records reviews and perform analysis of complex datasets and systems. This position requires exceptional written and oral communications, problem-solving skills, clinical experience in multiple settings of varying complexity and experience with children and adult populations.

This position will require knowledge of federal and state regulations, Medicaid and Medicare programs, systems analyses and research methods. This includes the ability to develop, establish and implement prepayment review criteria within multiple service areas. In addition, the ability to process prepayment reviews of Medicaid services according to established medical necessity criteria, administrative code and other requirements.

Your role in our mission
• Knowledge of current medical concepts, practices, and techniques.
• Ability to assess statistical data and reports regarding health service utilization patterns.
• Knowledge of laws, statutes, regulations, and rules relating to the state Medicaid program / Knowledge of federal and state legislation pertaining to Title XIX, Title XVIII, Title XX, and Title III / Ability to incorporate medical knowledge and experience into the development of medical policy, administrative rules, and medical standards / Ability to develop standards and guidelines for use in monitoring medical practice patterns / Thorough professional knowledge of existing state agency Medicaid covered services and reimbursement policy for the purposes of analysis, development of recommendations, and implementation of accepted recommendations.
• Ability to use medical and financial records and claims and claims data to obtain documentation necessary to support audit or investigative findings / Knowledge of Generally Accepted Auditing Standards / Knowledge and skill in the use of computer accessible databases to support audit activities and in the use of a technology to conduct pre-payment review audits including the ability to review and analyze computer generated reports / Extensive knowledge of hardware and software technology and networking for maintaining parity with technological changes and advances in the health care industry / Knowledge of program, financial, and accounting systems and procedures used by the various health care entities to manage the business of the entity such as how health care providers keep patient accounts showing charges and payments and how billing clerks prepare claims for reimbursement from third party payors and the specialized governmental or industry accounting and auditing standards or audit guides used to audit the provider.
• Ability to organize, prepare, summarize, and present in reports information gathered in audit/investigations from various sources in a usable manner to arrive at valid findings and conclusions / Extensive knowledge of technical writing, publication organization, preparation and format / Ability to express position of the State on Medicaid issues, utilizing both oral and written communication skills, in audit and investigative reports, formal exit conferences, and departmental meetings in an organized, intelligent and concise manner / Knowledge of records maintained by various health care providers and the ability to inspect medical records, patient charts, financial statements, documentation of transactions, invoices, payroll records, and claims.

What we’re looking for
• Degree in nursing
• Three (3) or more years of nursing experience
• Experience working with case management practices and clinical record review
• Current Wisconsin license as a Registered Nurse by the Wisconsin Department of Safety and Professional Services.
• utilization review and procedure coding experience

What you should expect in this role
• Remote (work from home) with occasional travel required to the office at 1 West Wilson, Madison, WI
• Must be a resident of Wisconsin
• Must be a currently licensed Registered Nurse

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The pay range for this position is $76,900 – $105,000 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.

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 and visit our for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be 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), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.

Expected salary: $76900 – 105000 per year

Location: Madison, WI

Job date: Fri, 22 Sep 2023 07:28:50 GMT

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