Remote RN Consultant - Prior Authorization (Medicaid)

Gainwell Technologies LLC; Seattle (WA); Remote; USD 91,000 - 130,000; Full time

Benefits offered by this job

401(k) match

Health benefits

Flexible vacation policy

Educational assistance

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 fully remote role supports providers and stakeholders while ensuring compliance with state policies and clinical standards.

You will adjudicate requests, collect needed information, and document decisions in MMIS.

Qualifications

• Bachelor's degree in Nursing or equivalent.
• Current RN license in Wisconsin or eligible for Wisconsin licensure.
• Minimum of 5 years nursing experience.
• Prior Authorization and/or Utilization Review experience.
• Knowledge of Medicaid programs preferred.
• Strong clinical decision-making and communication skills.
• Ability to interpret policies and clinical documentation.
• Strong organizational skills and ability to manage priorities.

Responsibilities

• Review and adjudicate prior authorization requests based on medical necessity and policy guidelines.
• Evaluate clinical documentation and obtain additional information from providers as needed.
• Enter determinations into the Medicaid Management Information System (MMIS).
• Serve as a clinical subject matter expert for providers and internal/external stakeholders.
• Educate providers on prior authorization requirements and submissions.
• Collaborate with leadership and teams to support program objectives.
• Identify opportunities for process improvements and policy enhancements.

Skills

Nursing experience

Communication skills

Organizational skills

Clinical decision making

Cross-functional collaboration

Education

Bachelor's degree in Nursing

Active RN license

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 fully remote role supports providers and stakeholders while ensuring compliance with state policies and clinical standards.

You will adjudicate requests, collect needed information, and document decisions in MMIS.