Remote RN: Prior Authorization & Medical Review Expert

Gainwell Technologies LLC; Columbus (OH); À distance; USD 91 000 - 130 000; Plein temps

Avantages offerts par ce poste

Flexible vacation policy

401(k) match

Health benefits

Educational assistance

Leadership academies

Development academies

Résumé du poste

Gainwell Technologies is seeking a Prior Authorization Registered Nurse Consultant - Personal Care Services. In this fully remote role, you will review prior authorization requests and determine medical necessity for Personal Care Services and Private Duty Nursing within Medicaid programs.

You will adjudicate requests, evaluate clinical documentation, enter determinations into MMIS, educate providers, and collaborate with leadership and state stakeholders to support program objectives.

Qualifications

• Bachelor's degree in Nursing or equivalent experience.
• Current RN license in Wisconsin or ability to obtain 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 knowledge of medical necessity.
• Excellent communication and interpersonal skills.
• Ability to interpret policies and clinical documentation.
• Strong organizational skills and ability to manage priorities.
• Experience collaborating with cross-functional teams.
• Proficiency with systems used to support authorization and review processes.

Responsabilités

• 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.

Connaissances

Strong communication

Organizational skills

Critical thinking

Cross-functional collaboration

Attention to detail

Formation

Bachelor's degree in Nursing

Outils

MMIS

Description du poste

Gainwell Technologies is seeking a Prior Authorization Registered Nurse Consultant - Personal Care Services. In this fully remote role, you will review prior authorization requests and determine medical necessity for Personal Care Services and Private Duty Nursing within Medicaid programs.

You will adjudicate requests, evaluate clinical documentation, enter determinations into MMIS, educate providers, and collaborate with leadership and state stakeholders to support program objectives.