Remote Prior Authorization RN Consultant – Medicaid

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

Benefits offered by this job

Flexible vacation policy

401(k) employer match

Comprehensive health benefits

Educational assistance

Job summary

Gainwell Technologies is seeking a Personal Care RN Consultant - Wisconsin to apply clinical expertise to review prior authorization requests and determine medical necessity for Personal Care and Private Duty Nursing within Medicaid programs. This remote role supports providers and stakeholders while aligning with state policy guidelines.

You'll adjudicate requests, evaluate documentation, and enter determinations into MMIS.

Qualifications

• Bachelor's degree in Nursing or equivalent.
• Current RN license in Wisconsin, or able to obtain Wisconsin licensure before start.
• 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 clinical decision-making and policy interpretation skills.
• Excellent verbal and written communication.
• Strong organization and ability to manage priorities.

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

Nursing experience

Clinical decision-making

Interpersonal communication

Policy interpretation

Organization

Cross-functional collaboration

Education

Bachelor's degree in Nursing

Current RN license in Wisconsin

RN licensure eligibility Wisconsin

Tools

MMIS

Job description

Gainwell Technologies is seeking a Personal Care RN Consultant - Wisconsin to apply clinical expertise to review prior authorization requests and determine medical necessity for Personal Care and Private Duty Nursing within Medicaid programs. This remote role supports providers and stakeholders while aligning with state policy guidelines.

You'll adjudicate requests, evaluate documentation, and enter determinations into MMIS.