Remote RN | Prior Authorization & Medicaid Specialist

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

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 aligning with state policy guidelines and clinical standards.

The successful candidate will possess a Wisconsin RN license (or eligible for Wisconsin licensure), five years of nursing experience, and prior authorization or

Qualifications

• Bachelor's degree in Nursing or equivalent experience.
• Current RN license in Wisconsin, or eligible for WI licensure.
• Minimum of 5 years nursing experience.
• Prior Authorization and/or Utilization Review experience.
• Knowledge of Wisconsin Medicaid or other state Medicaid programs preferred.
• Strong interpretation of policies and clinical documentation.

Responsibilities

• Review and adjudicate prior authorization requests based on medical necessity.
• Evaluate clinical documentation and obtain clarification from providers when needed.
• Enter determinations into MMIS and support timely decisions.
• Serve as clinical subject matter expert for providers and internal teams.
• Educate providers on prior authorization requirements and submissions.
• Collaborate with leadership and stakeholders to support program objectives.
• Identify process improvement opportunities and propose enhancements to programs.

Skills

Nursing experience

Clinical decision-making

Communication skills

Organizational skills

Collaboration

Education

Bachelor's degree in Nursing

Tools

MMIS experience

Healthcare IT 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 aligning with state policy guidelines and clinical standards.

The successful candidate will possess a Wisconsin RN license (or eligible for Wisconsin licensure), five years of nursing experience, and prior authorization or