Behavioral Health Utilization Review Specialist

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

Benefits offered by this job

Remote work

Full-time

Generous vacation policy

401(k) match

Health benefits

Educational assistance

Development academies

Job summary

Gainwell Technologies LLC in the United States is seeking a healthcare utilization reviewer to adjudicate Behavioral Health prior authorizations based on medical necessity and eligibility, following state guidelines. The role focuses on Medicaid-related programs with no direct patient contact.

You will review submissions, enter outcomes into MMIS, participate in monthly meetings with stakeholders, and provide provider education. This 100% remote, full-time position offers growth and benefits.

Qualifications

• Master's degree in counseling, social work, marriage and family therapy or equivalent.
• Minimum of 5 years clinical work experience.
• Current LPC, LCSW, or LMFT license in Wisconsin (or ability to obtain WI license).
• CSAC or SAC license in Wisconsin (CSAC preferred).
• Knowledge of Wisconsin Medicaid or other state Medicaid programs.
• Experience in Utilization Management-Review preferred.
• Excellent computer skills and strong communication abilities.

Responsibilities

• Review and evaluate prior authorization submissions using multiple systems and obtain clarification when needed.
• Enter prior authorization outcomes into MMIS for processing.
• Participate in monthly leadership and stakeholder meetings with state partners.
• Provide education to providers regarding specific prior authorizations.
• Suggest process improvements for administration of medical programs.
• Review communications to providers and members on new or revised policies.

Skills

Clinical experience

Utilization management

Prior authorization

Policy interpretation

Excellent communication

Education

Master's degree in counseling/social work

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

Apply your expertise to adjudicate Behavioral Health prior authorizations based on medical necessity and eligibility, in accordance with State policy guidelines and accepted best practices. Specialty areas include Substance Use Disorder Treatment, Child and Adolescent Day Treatment. Adult Mental Health Day Treatment and In- Home Family Therapy. There are no direct patient interactions for this role, rather you will provide utilization review and quality assurance.

Your role in our mission

• Review and evaluate prior authorization submissions utilizing multiple computer systems, and when appropriate seek additional information or clarification from requesting providers.
• Enter prior authorization outcomes into the Medicaid Management Information System (MMIS) for processing.
• Participate in monthly meetings which leadership, operational staff support, clinical peers and State of Wisconsin stakeholders.
• Provide assistance and education to the provider community related to specific prior authorization submissions, when applicable.
• Offer analysis and recommendations on methods and potential process improvements related to the administration and application of medical programs that you support.
• Review communications to providers and members on new/revised policies.

What we’re looking for

• Master’s degree in counseling, social work, marriage and family therapy or equivalent
• A minimum of 5 years clinical work experience
• Current LPC, LCSW, or LMFT license in the state of WI (or license from another state and ability to obtain WI license prior to position start date)
• CSAC or SAC license in the state of WI (CSAC preferred)
• Knowledge of and/or experience working with the Wisconsin Medicaid program (or other state’s Medicaid programs) desired
• Previous experience in Utilization Management-Review preferred
• Excellent computer skills
• Excellent interpersonal, oral, and written communication skills.
• Ability to meet deadlines and manage priorities with minimal direct supervision
• Experience working with various partners or team members toward shared goals
• Ability to communicate effectively and interpret policies and procedures

What you should expect in this role

• 100% Remote home office.
• Full-time position.

Applications will be accepted through November 2, 2026.

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.

• generous, flexible vacation policy
• a 401(k) employer match
• comprehensive health benefits
• educational assistance
• 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 and visit our Careers site 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.

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.