Remote RN Medical Advisor - Prior Authorization Expert

Gainwell Technologies LLC; United States; Remote; USD 91,000 - 130,000; Full time

Benefits offered by this job

401(k) match

Health benefits

Educational assistance

Generous, flexible vacation policy

Job summary

Gainwell Technologies LLC in Wisconsin (remote role) is seeking an Advisor Medical Expert: a Prior Authorization Registered Nurse Consultant who will review requests and determine medical necessity for Personal Care Services and Private Duty Nursing within Medicaid programs.

In this virtual role, you will support providers and stakeholders, ensure policy alignment, document decisions in MMIS, and contribute to high-quality care delivery while collaborating with state agencies and internal teams.

Qualifications

• Bachelor’s degree in nursing or equivalent combination of education and experience.
• Current RN license in Wisconsin, or active RN license in another state with ability to obtain Wisconsin licensure prior to start date.
• Minimum of 5 years of nursing experience.
• Prior Authorization and/or Utilization Review experience.

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

RN license Wisconsin

Nursing experience

Prior Authorization / Utilization

Medical policy interpretation

Communication skills

Education

Bachelor's in Nursing

Tools

MMIS

Healthcare IT systems

Job description

Gainwell Technologies LLC in Wisconsin (remote role) is seeking an Advisor Medical Expert: a Prior Authorization Registered Nurse Consultant who will review requests and determine medical necessity for Personal Care Services and Private Duty Nursing within Medicaid programs.

In this virtual role, you will support providers and stakeholders, ensure policy alignment, document decisions in MMIS, and contribute to high-quality care delivery while collaborating with state agencies and internal teams.