Remote Prior Authorization Nurse Consultant

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

Benefits offered by this job

401(k) match

Health benefits

Educational assistance

Flexible vacation policy

Job summary

Gainwell Technologies seeks an Advisor Medical Expert, a remote RN consultant focused on prior authorization for Personal Care Services and Private Duty Nursing within Medicaid. You will review requests for medical necessity, ensure policy alignment, and collaborate with providers, state stakeholders, and internal teams to support program objectives.

The role offers flexible hours, a supportive learning environment, and clear paths for career development within a forward-thinking healthcare

Qualifications

• 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.
• 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.

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

RN license

Clinical decision-making

Communication skills

Time management

Collaboration

Computer systems proficiency

Education

Bachelor's degree in Nursing

Tools

MMIS

Job description

Gainwell Technologies seeks an Advisor Medical Expert, a remote RN consultant focused on prior authorization for Personal Care Services and Private Duty Nursing within Medicaid. You will review requests for medical necessity, ensure policy alignment, and collaborate with providers, state stakeholders, and internal teams to support program objectives.

The role offers flexible hours, a supportive learning environment, and clear paths for career development within a forward-thinking healthcare