Job Overview: Gainwell Technologies is seeking a skilled DRG Nurse Reviewer for Appeals and Hearings in a fully remote capacity. This critical role involves reviewing and appealing Diagnosis-Related Group (DRG) claims to ensure fair and accurate healthcare reimbursements for government and commercial payers. As a key member of our utilization review team, you will leverage your nursing expertise to analyze medical records, validate coding, and represent cases in hearings, contributing to efficient healthcare delivery and compliance with regulatory standards. Key Responsibilities: Conduct thorough clinical reviews of inpatient claims to validate DRG assignments, identifying discrepancies in documentation, coding, and medical necessity. Prepare detailed appeal letters and supporting documentation for denied claims, collaborating with coders, physicians, and payers to overturn decisions. Participate in administrative hearings, presenting evidence and testifying on clinical rationales to secure approvals. Maintain up-to-date knowledge of CMS guidelines, ICD-10, MS-DRG methodologies, and state-specific regulations. Document all review activities in proprietary systems, track outcomes, and provide feedback to improve internal processes. Mentor junior reviewers and contribute to team training on complex DRG scenarios. Required Qualifications: Active Registered Nurse (RN) license in good standing, with a BSN preferred. Minimum of 3-5 years of recent clinical nursing experience in acute care settings such as med-surg, ICU, or case management. At least 2 years of DRG validation, utilization review, or appeals experience in a payer or auditing environment. Certification in coding or case management (e.g., CPC, CCM, CPMA) is highly desirable. Proficiency with EHR systems, claims processing software, and Microsoft Office Suite. Skills: Strong analytical skills to dissect complex medical records and apply DRG logic accurately. Excellent written and verbal communication for crafting persuasive appeals and presenting in hearings. Attention to detail and ability to meet strict deadlines in a high-volume environment. Knowledge of healthcare reimbursement policies, including Medicare/Medicaid rules. Independent worker with solid organizational skills for remote productivity. Problem-solving mindset to navigate payer denials effectively. Company Info: Gainwell Technologies is a leading healthcare technology company dedicated to improving health outcomes through innovative solutions. We partner with state and federal agencies to modernize Medicaid programs, process billions in claims annually, and support over 50 million beneficiaries. Our mission-driven culture emphasizes work-life balance, collaboration, and professional growth in a dynamic, remote-first environment. Benefits: Competitive salary with performance-based incentives. Comprehensive health, dental, and vision insurance with low premiums. Generous 401(k) matching, paid time off starting at 20 days, and flexible remote work setup. Professional development stipend, tuition reimbursement, and wellness programs including mental health support. Growth Opportunities: Advance to Senior Reviewer, Appeals Manager, or Clinical Director roles. Access ongoing training in emerging healthcare tech like AI-driven claims analysis. Join cross-functional teams for process improvement projects and contribute to industry publications. Gainwell fosters internal mobility with clear career paths and leadership development programs.