Gainwell Technologies LLC·Perry County, Ohio
The DRG Nurse Reviewer Appeals and Hearings coordinates and performs all appeal-related duties, including analyzing and responding to provider appeals and preparing case files for hearings. The role also involves participating in hearings and assisting in training new reviewers.
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.
Sign-On bonuses are available for highly qualified candidates.
We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings.
Your role in our mission
Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely.
Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards.
Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director.
Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification.
Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
What we're looking for
Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required
5+ years clinical experience or 5+ years medical record coding experience preferred
Working knowledge of the appeals and hearings process
Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions.
Ability to multi-task in a fast-paced production environment.
This position is for pipeline purposes, and we welcome applications on an ongoing basis.
The pay range for this position is $95,000.00 - $110,000.00 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 [https://jobs.gainwelltechnologies.com/content/benefits/?locale=en_US], 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 [https://www.gainwelltechnologies.com/] and visit our Careers site [https://jobs.gainwelltechnologies.com/] 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.
Candidates must have an active, unrestricted RN license and relevant coding certifications. A minimum of 5 years of clinical or medical record coding experience is preferred, along with strong communication skills.
Market context
In Ohio, nursing roles like LPN positions are typically supported by steady demand across clinics, long-term care, and other care settings. Competition often centers on active state licensure, relevant bedside experience, and readiness to work within team-based care environments. Review the AI-summarized requirements and benefits here to save time, then confirm your LPN credential and tailor your application to the settings where you have the strongest experience.