Remote Behavioral Health Utilization Review Specialist

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

Benefits offered by this job

401(k) employer match

Health benefits

Educational assistance

Flexible vacation policy

Job summary

Gainwell Technologies seeks a Behavioral Health Prior Authorization reviewer to adjudicate authorizations based on medical necessity and policy guidelines, with focus areas including Substance Use Disorder Treatment and Child/Adolescent Day Treatment. This role involves utilization review and quality assurance without direct patient contact.

You will work remotely, review submissions across multiple systems, and collaborate with state stakeholders to ensure compliant, timely decisions.

Qualifications

• Master's degree in counseling, social work, marriage and family therapy or equivalent.
• Current WI LPC, LCSW, or LMFT license (or eligible to obtain WI license).
• CSAC or SAC license in WI (CSAC preferred).
• Knowledge of Wisconsin Medicaid or other state Medicaid programs.
• Excellent interpersonal, oral, and written communication skills.
• Ability to meet deadlines and manage priorities with minimal supervision.

Responsibilities

• Review and evaluate prior authorization submissions using multiple computer systems and request clarification from providers when needed.
• Enter prior authorization outcomes into the MMIS for processing.
• Participate in monthly meetings with leadership, staff, clinicians, and State of WI stakeholders.
• Provide education to the provider community related to PA submissions when applicable.
• Offer analysis and recommendations on methods and process improvements for medical programs you support.
• Review communications to providers and members on new or revised policies.

Education

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

WI LPC license (or eligible)

WI CSAC or SAC license

Job description

Gainwell Technologies seeks a Behavioral Health Prior Authorization reviewer to adjudicate authorizations based on medical necessity and policy guidelines, with focus areas including Substance Use Disorder Treatment and Child/Adolescent Day Treatment. This role involves utilization review and quality assurance without direct patient contact.

You will work remotely, review submissions across multiple systems, and collaborate with state stakeholders to ensure compliant, timely decisions.