Remote RN Consultant: Medicaid Prior Authorization

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

Leadership and technical development

Job summary

Gainwell Technologies is seeking an experienced Registered Nurse Consultant to review Medicaid prior authorization requests and determine medical necessity in line with state guidelines. You will support providers, collaborate with internal teams, and help deliver high-quality, cost-effective healthcare services through timely clinical reviews.

This fully remote role requires strong clinical assessment, knowledge of Medicaid policies, and the ability to work across multiple systems.

Qualifications

• Active RN license in Wisconsin.
• Experience reviewing prior authorizations and applying medical necessity criteria.
• Knowledge of Medicaid programs and healthcare policy guidelines.
• Strong clinical assessment and critical thinking skills.
• Ability to interpret clinical documentation and make sound coverage determinations.
• Excellent interpersonal, verbal, and written communication skills.
• Experience working with multiple computer systems and applications.
• Strong organizational skills with the ability to manage multiple priorities and concurrent activities.
• Ability to work independently and adapt to changing priorities and workloads.
• Experience collaborating with providers, internal teams, and external stakeholders.
• Ability to contribute to policy development, process improvement initiatives, and complex projects.

Responsibilities

• Reviewing and adjudicating prior authorization requests across multiple service areas based on medical necessity, eligibility requirements, and accepted clinical practices.
• Evaluating prior authorization submissions and obtaining additional information or clarification from providers when needed.
• Summarizing clinical information and rendering authorization decisions, including approvals, modifications, returns, or denials.
• Entering authorization outcomes into the Medicaid Management Information System (MMIS) for processing.
• Serving as a clinical subject matter expert and resource for providers, internal teams, and state stakeholders.
• Providing education and support to the provider community regarding authorization requirements and submissions.
• Participating in meetings with leadership, operational staff, clinical peers, and state partners.
• Supporting clinical policy development and providing recommendations for program and process improvements.
• Reviewing provider and member communications related to new or revised policies.
• Responding to provider inquiries and returning provider phone messages.
• Building and maintaining collaborative relationships with Gainwell and state agency partners.

Skills

RN license

Medicaid experience

Prior authorization

Clinical assessment

Policy knowledge

Communication skills

Multi-system experience

Organization

Independent worker

Collaboration

Policy improvement

Tools

MMIS

Job description

Gainwell Technologies is seeking an experienced Registered Nurse Consultant to review Medicaid prior authorization requests and determine medical necessity in line with state guidelines. You will support providers, collaborate with internal teams, and help deliver high-quality, cost-effective healthcare services through timely clinical reviews.

This fully remote role requires strong clinical assessment, knowledge of Medicaid policies, and the ability to work across multiple systems.