Remote Behavioral Health Prior Authorization Specialist

Gainwell Technologies LLC; Ohio; Remote; USD 91,000 - 130,000; Full time

Job summary

Gainwell Technologies is seeking a Behavioral Health Prior Authorization Reviewer to adjudicate based on medical necessity and state guidelines in a 100% remote role. You will handle substance use, child/adolescent day treatment, and home therapy cases with no direct patient contact, focusing on utilization review and quality assurance.

You will review submissions across systems, enter outcomes into MMIS, and participate in stakeholder meetings while educating providers and recommending process

Qualifications

• 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.
• 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.

Responsibilities

• 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.

Skills

Excellent computer skills

Communication skills

Time management

Team collaboration

Education

Master's degree in counseling, social work, marriage and family therapy or equivalent

LPC, LCSW, or LMFT license in WI (or eligible to obtain WI license)

CSAC or SAC license in WI (CSAC preferred)

Job description

Gainwell Technologies is seeking a Behavioral Health Prior Authorization Reviewer to adjudicate based on medical necessity and state guidelines in a 100% remote role. You will handle substance use, child/adolescent day treatment, and home therapy cases with no direct patient contact, focusing on utilization review and quality assurance.

You will review submissions across systems, enter outcomes into MMIS, and participate in stakeholder meetings while educating providers and recommending process