Senior Clinical Quality Lead: Prior Authorization (Remote)

Gainwell Technologies LLC; United States; Remote; USD 72,000 - 102,000; Full time

Benefits offered by this job

401(k) employer match

Health benefits

Educational assistance

Flexible vacation policy

Job summary

Gainwell Technologies seeks an Associate Manager, Clinical Quality to supervise QA activities for Prior Authorization reviews and drive accuracy, timeliness, and regulatory compliance. You will lead a team of quality auditors, monitor interrater reliability, and report performance and risks to leadership.

The role focuses on process improvement, training, and policy updates, with remote US work, up to 20% travel, and a competitive compensation package.

Qualifications

• Associate degree required; bachelor’s degree preferred.
• Current, unrestricted RN license required; additional utilization management, case management, or healthcare quality certification preferred.
• Working knowledge of Prior Authorization, utilization management, medical necessity review, adverse determination processes, and applicable regulatory and accreditation requirements.
• Demonstrated ability to apply evidence-based clinical criteria, health plan policies, benefit requirements, and clinical judgment consistently and accurately.
• Minimum 5 years of experience in Prior Authorization, utilization management, clinical review, or healthcare quality assurance.
• Minimum 2 years of leadership or quality assurance experience in a health plan, managed care, utilization management, or healthcare setting.

Responsibilities

• Supervise the Prior Authorization quality review program, including policies, procedures, and controls supporting compliance with standards, regulations, accreditation requirements, and contracts.
• Develop and maintain quality assurance processes, audit methodologies, and performance benchmarks for medical and behavioral health Prior Authorization reviews.
• Supervise and mentor clinical quality auditors and reviewers through education, coaching, and performance feedback. Monitor and report quality, accuracy, timeliness, productivity, denial rationale, and interrater reliability metrics.
• Identify trends, root causes, and improvement opportunities in clinical criteria application, documentation, review consistency, and workflows.
• Analyze audit results, appeals, complaints, and regulatory findings to identify issues and recommend corrective actions.
• Prepare reports and dashboards for leadership on performance, audit outcomes, risks, and improvement initiatives.
• Ensure Prior Authorization reviews are completed accurately, consistently, and within required timeframes.
• Develop and deliver training based on audit findings, policy updates, and performance trends.
• Maintain knowledge of CMS, Medicaid, accreditation standards, clinical policies, and industry practices.
• Lead quality improvement initiatives that enhance accuracy, consistency, efficiency, and experience.
• Serve as a subject matter expert for new tools, automation, operational readiness, and escalated quality issues.
• Manage individual and team performance to meet or exceed performance standards.
• Perform other duties as assigned.

Skills

Leadership

Quality assurance

Prior Authorization

Utilization management

Clinical review

Analytical thinking

Communication

Problem-solving

Education

Associate degree

Bachelor’s degree

Job description

Gainwell Technologies seeks an Associate Manager, Clinical Quality to supervise QA activities for Prior Authorization reviews and drive accuracy, timeliness, and regulatory compliance. You will lead a team of quality auditors, monitor interrater reliability, and report performance and risks to leadership.

The role focuses on process improvement, training, and policy updates, with remote US work, up to 20% travel, and a competitive compensation package.