Remote RN Advisor – Medicaid Prior Authorization

Gainwell Technologies LLC; Madison (WI); Remote; USD 91,000 - 130,000; Full time

Benefits offered by this job

Remote work

401(k) match

Health benefits

Educational assistance

Development academies

Flexible vacation

Job summary

Gainwell Technologies is seeking a Prior Authorization Registered Nurse Consultant - Personal Care Services to review prior authorization requests and determine medical necessity for Medicaid programs. This remote role supports providers and stakeholders, ensuring authorization decisions align with state policy guidelines, clinical standards, and program requirements.

Your work will help ensure medically necessary services for Medicaid members, contributing to regulatory compliance and

Qualifications

• Bachelor's degree in Nursing required.
• Current RN license in Wisconsin or able to obtain Wisconsin licensure before start date.
• Minimum of 5 years 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.
• Ability to interpret policies, procedures, and clinical documentation.
• 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.

Responsibilities

• Review and adjudicate prior authorization requests based on medical necessity, eligibility, and state policy guidelines.
• Evaluate clinical documentation and obtain additional information or clarification from providers when needed.
• Enter authorization determinations into the Medicaid Management Information System (MMIS).
• Serve as a clinical subject matter expert and resource for providers, internal teams, and external stakeholders.
• Provide education and guidance to the provider community regarding prior authorization requirements and submissions.
• Collaborate with leadership, operational teams, clinical peers, and state stakeholders to support program objectives.
• Identify opportunities for process improvements and recommend enhancements to supported medical programs.
• Assist with the review of provider and member communications related to new or revised policies and procedures.

Skills

RN

Nursing

Clinical documentation

Medical necessity review

Communication skills

Cross-functional collaboration

Education

Bachelor's degree in Nursing

Tools

MMIS systems

Job description

Gainwell Technologies is seeking a Prior Authorization Registered Nurse Consultant - Personal Care Services to review prior authorization requests and determine medical necessity for Medicaid programs. This remote role supports providers and stakeholders, ensuring authorization decisions align with state policy guidelines, clinical standards, and program requirements.

Your work will help ensure medically necessary services for Medicaid members, contributing to regulatory compliance and