Personal Care RN

Jobtailor; Deutschland; Remote; EUR 60.000 - 78.000; Vollzeit

Zusammenfassung

Jobtailor is recruiting a registered nurse to adjudicate prior authorization requests for Wisconsin Medicaid programs. The role requires clinical judgment, collaboration with providers and internal teams, and guidance on submissions.

You will evaluate medical necessity and document outcomes within MMIS. Ideal candidates have 5+ years of nursing experience, knowledge of Medicaid programs, and strong communication skills to educate providers and stakeholders.

Qualifikationen

• Bachelor's degree in Nursing or equivalent education/experience.
• Active RN license in Wisconsin or eligible to obtain Wisconsin licensure before start date.
• Minimum 5 years of nursing experience.
• Prior Authorization and/or Utilization Review experience.
• Knowledge of Wisconsin Medicaid or other state Medicaid programs preferred.
• Strong understanding of medical necessity review and clinical decision-making.
• Excellent interpersonal, verbal, and written communication skills.
• Ability to interpret policies and clinical documentation.
• Strong organizational skills with ability to manage priorities.
• Experience collaborating with cross-functional teams and stakeholders.
• Proficiency with Medicaid Management Information System (MMIS) and related systems.

Aufgaben

• Review and adjudicate prior authorization requests based on medical necessity, eligibility, and state policy guidelines
• Evaluate clinical documentation and obtain additional information or clarification from providers
• Enter authorization determinations into the MMIS
• Serve as a clinical subject matter expert and resource for providers, internal teams, and external stakeholders
• Provide education and guidance to the provider community regarding prior authorization requirements and submissions
• Collaborate with leadership, operational teams, clinical peers, and state stakeholders to support program objectives
• Identify opportunities for process improvements and recommend enhancements to supported medical programs
• Assist with reviewing provider and member communications related to new or revised policies and procedures

Kenntnisse

Nursing experience

Medical necessity review

Clinical decision-making

Policy interpretation

Process improvement

Interpersonal communication

Verbal communication

Written communication

Organizational skills

Collaboration

Ausbildung

Bachelor's Degree in Nursing

Tools

MMIS

Authorization systems

Jobbeschreibung

• Review and adjudicate prior authorization requests based on medical necessity, eligibility, and state policy guidelines


• Evaluate clinical documentation and obtain additional information or clarification from providers


• Enter authorization determinations into the Medicaid Management Information System (MMIS)


• Serve as a clinical subject matter expert and resource for providers, internal teams, and external stakeholders


• Provide education and guidance to the provider community regarding prior authorization requirements and submissions


• Collaborate with leadership, operational teams, clinical peers, and state stakeholders to support program objectives


• Identify opportunities for process improvements and recommend enhancements to supported medical programs


• Assist with reviewing provider and member communications related to new or revised policies and procedures

Requirements

• Bachelor's degree in Nursing or an equivalent combination of education and experience


• Current RN license in Wisconsin, or an active RN license in another state with the ability to obtain Wisconsin licensure prior to the start date


• Minimum of 5 years of nursing experience


• Prior Authorization and/or Utilization Review experience


• Knowledge of Wisconsin Medicaid or other state Medicaid programs preferred


• Strong understanding of medical necessity review and clinical decision-making


• Excellent interpersonal, verbal, and written communication skills


• Ability to interpret policies, procedures, and clinical documentation


• Strong organizational skills with the ability to manage priorities and meet deadlines independently


• Experience collaborating with cross-functional teams and stakeholders


• Proficiency with computer systems and technology used to support authorization and review processes


• Availability to work weekends as needed

Core Competencies

Demonstrates expertise in Prior Authorization and Utilization Review, with a strong understanding of Medical Necessity and Clinical Decision-Making. Proficient in collaborating with cross-functional teams and providing education to the provider community regarding Medicaid policies and procedures.

Highest-signal resume keywords

• RN License in Wisconsin


• Prior Authorization Experience


• Utilization Review Experience


• Knowledge of Wisconsin Medicaid


• Clinical Documentation Evaluation

ATS Optimization Keywords

Hard Skills

• Nursing Experience


• Medical Necessity Review


• Clinical Decision-Making


• Policy Interpretation


• Process Improvement

Soft Skills

• Interpersonal Communication


• Verbal Communication


• Written Communication


• Organizational Skills


• Collaboration

Certifications & Qualifications

• Bachelor's Degree in Nursing


• Current RN License

Industry Keywords

• Prior Authorization


• Utilization Review


• State Policy Guidelines


• Provider Community Education


• Cross-Functional Collaboration

Tools & Technologies

• Medicaid Management Information System (MMIS)


• Computer Systems for Authorization Processes