Advisor Medical Expert

Gainwell Technologies LLC; Columbus (OH); Remote; USD 91,000 - 130,000; Full time

Benefits offered by this job

Flexible vacation policy

401(k) match

Health benefits

Educational assistance

Leadership academies

Development academies

Job summary

Gainwell Technologies is seeking a Prior Authorization Registered Nurse Consultant - Personal Care Services. In this fully remote role, you will review prior authorization requests and determine medical necessity for Personal Care Services and Private Duty Nursing within Medicaid programs.

You will adjudicate requests, evaluate clinical documentation, enter determinations into MMIS, educate providers, and collaborate with leadership and state stakeholders to support program objectives.

Qualifications

• Bachelor's degree in Nursing or equivalent experience.
• Current RN license in Wisconsin or ability to obtain Wisconsin licensure.
• Minimum of 5 years nursing experience.
• Prior Authorization and/or Utilization Review experience.
• Knowledge of Medicaid programs preferred.
• Strong clinical decision-making and knowledge of medical necessity.
• Excellent communication and interpersonal skills.
• Ability to interpret policies and clinical documentation.
• Strong organizational skills and ability to manage priorities.
• Experience collaborating with cross-functional teams.
• Proficiency with systems used to support authorization and review processes.

Responsibilities

• Reviewing and adjudicating prior authorization requests based on medical necessity, eligibility, and state policy guidelines.
• Evaluating clinical documentation and obtaining additional information or clarification from providers when needed.
• Entering authorization determinations into the Medicaid Management Information System (MMIS).
• Serving as a clinical subject matter expert and resource for providers, internal teams, and external stakeholders.
• Providing education and guidance to the provider community regarding prior authorization requirements and submissions.
• Collaborating with leadership, operational teams, clinical peers, and state stakeholders to support program objectives.
• Identifying opportunities for process improvements and recommending enhancements to supported medical programs.
• Assisting with the review of provider and member communications related to new or revised policies and procedures.

Skills

Strong communication

Organizational skills

Critical thinking

Cross-functional collaboration

Attention to detail

Education

Bachelor's degree in Nursing

Tools

MMIS

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

As a Prior Authorization Registered Nurse Consultant - Personal Care Services, you will apply your clinical expertise to review prior authorization requests and determine medical necessity for Personal Care Services and Private Duty Nursing within Medicaid programs. In this remote role, you will support providers and stakeholders by ensuring authorization decisions align with state policy guidelines, clinical standards, and program requirements while contributing to high-quality care delivery.

Your role in our mission

In this role, you will help ensure Medicaid members receive appropriate, medically necessary services through accurate and timely prior authorization reviews. Your expertise will support quality outcomes, regulatory compliance, and effective healthcare program administration by:

• Reviewing and adjudicating prior authorization requests based on medical necessity, eligibility, and state policy guidelines.
• Evaluating clinical documentation and obtaining additional information or clarification from providers when needed.
• Entering authorization determinations into the Medicaid Management Information System (MMIS).
• Serving as a clinical subject matter expert and resource for providers, internal teams, and external stakeholders.
• Providing education and guidance to the provider community regarding prior authorization requirements and submissions.
• Collaborating with leadership, operational teams, clinical peers, and state stakeholders to support program objectives.
• Identifying opportunities for process improvements and recommending enhancements to supported medical programs.
• Assisting with the review of provider and member communications related to new or revised policies and procedures.

What we're looking for

• 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 to achieve shared goals.
• Proficiency with computer systems and technology used to support authorization and review processes.

What you should expect in this role

• Fully remote work environment.
• Fast-paced environment requiring strong critical thinking, organization, and attention to detail.
• Weekend hours may be flexible; however, candidates must be available to work weekends as needed to support operational requirements.

The pay range for this position is $90,900.00 - $129,900.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

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.

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.

Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.