Remote RN Consultant: Medicaid Prior Authorization

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

Benefits offered by this job

401(k) match

Health benefits

Educational assistance

Flexible vacation policy

Leadership and technical development

Job summary

Gainwell Technologies is seeking a Multi Benefit Services RN Consultant to review Medicaid prior authorization requests and determine medical necessity in line with state policy guidelines. You will support providers, collaborate with internal teams, and drive high-quality, cost-effective care through timely clinical reviews.

You will help ensure Medicaid members receive appropriate services while supporting program integrity, quality outcomes, and compliance with state requirements.

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.
• Excellent interpersonal, verbal, and written communication skills.
• Experience working with multiple computer systems and applications.
• Ability to work independently and adapt to changing priorities and workloads.

Responsibilities

• Review and adjudicate prior authorization requests based on medical necessity, eligibility requirements, and accepted clinical practices.
• Evaluate prior authorization submissions and obtain additional information from providers as needed.
• Summarize clinical information and render authorization decisions (approvals, modifications, returns, denials).
• Enter authorization outcomes into the MMIS for processing.
• Serve as a clinical subject matter expert and resource for providers, internal teams, and state stakeholders.
• Provide education and support to the provider community regarding authorization requirements and submissions.
• Participate in meetings with leadership, operational staff, clinical peers, and state partners.
• Support clinical policy development and propose process improvements.
• Review provider and member communications related to new or revised policies.
• Respond to provider inquiries and manage provider messages.
• Build and maintain collaboration with Gainwell and state partners.

Skills

Clinical assessment

Prior authorization experience

Medicaid knowledge

Communication skills

Independent work

Tools

MMIS

Job description

Gainwell Technologies is seeking a Multi Benefit Services RN Consultant to review Medicaid prior authorization requests and determine medical necessity in line with state policy guidelines. You will support providers, collaborate with internal teams, and drive high-quality, cost-effective care through timely clinical reviews.

You will help ensure Medicaid members receive appropriate services while supporting program integrity, quality outcomes, and compliance with state requirements.