Remote Behavioral Health Prior Authorization Specialist

Gainwell Technologies; Northern (KY); Hybrid; USD 91,000 - 130,000; Full time

Benefits offered by this job

Flexible vacation policy

401(k) match

Health benefits

Educational assistance

Job summary

Gainwell Technologies seeks a Behavioral Treatment Services Prior Authorization Reviewer to adjudicate Medicaid behavioral treatment requests and determine medical necessity in a fully remote role. You will collaborate with providers and internal teams to ensure timely access to care, and support education on submission requirements.

The role emphasizes clinical expertise, policy interpretation, and cross-functional collaboration within a fast-paced healthcare environment.

Qualifications

• Minimum 5 years of Behavioral Treatment experience.
• Current BCBA license in Wisconsin or eligible for Wisconsin licensure before start date.
• Excellent interpersonal, verbal, and written communication skills.
• Ability to interpret and communicate policies and procedures.
• Strong organizational skills with the ability to manage priorities and meet deadlines.

Responsibilities

• Ensure Medicaid members receive timely access to behavioral treatment services through accurate prior authorization reviews.
• Evaluate medical necessity and eligibility according to state Medicaid policies and guidelines.
• Review submissions and request additional information from providers when needed.
• Enter determinations into MMIS for processing.
• Provide education and guidance to providers regarding prior authorization requirements.
• Review provider and member communications about policies.
• Serve as a clinical SME for providers and internal/external stakeholders.
• Support efficient, accurate, and compliant authorization processes.

Skills

Behavioral Treatment

BCBA license

Interpersonal skills

Policy interpretation

Organizational skills

Cross-functional collaboration

Medicaid experience

Job description

Gainwell Technologies seeks a Behavioral Treatment Services Prior Authorization Reviewer to adjudicate Medicaid behavioral treatment requests and determine medical necessity in a fully remote role. You will collaborate with providers and internal teams to ensure timely access to care, and support education on submission requirements.

The role emphasizes clinical expertise, policy interpretation, and cross-functional collaboration within a fast-paced healthcare environment.