Prior Authorization Registered Nurse Consultant

Job not on LinkedIn

🔥 0 minutes ago

🧀 Wisconsin – Remote

🧀 Wisconsin – Remote

💵 $90.9k - $129.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Review and adjudicate prior authorization requests based on medical necessity, eligibility, and state policy guidelines • Evaluate clinical documentation and obtain additional information or clarification from providers when needed • Enter authorization determinations into the Medicaid Management Information System (MMIS) • Serve as a clinical subject matter expert and resource for providers, internal teams, and external stakeholders • Provide education and guidance to the provider community regarding prior authorization requirements and submissions • Collaborate with leadership, operational teams, clinical peers, and state stakeholders to support program objectives • Identify opportunities for process improvements and recommend enhancements to supported medical programs • Assist with reviewing provider and member communications related to new or revised policies and procedures

🎯 Requirements

• Bachelor's degree in Nursing or an equivalent combination of education and experience • Current RN license in Wisconsin, or an active RN license in another state with the ability to obtain Wisconsin licensure prior to the start date • Minimum of 5 years of nursing experience • Prior Authorization and/or Utilization Review experience • Knowledge of Wisconsin Medicaid or other state Medicaid programs preferred • Strong understanding of medical necessity review and clinical decision-making • Excellent interpersonal, verbal, and written communication skills • Ability to interpret policies, procedures, and clinical documentation • Strong organizational skills with the ability to manage priorities and meet deadlines independently • Experience collaborating with cross-functional teams and stakeholders • Proficiency with computer systems and technology used to support authorization and review processes • Must be available to work weekends as needed

🏖️ Benefits

• Flexible work hours • Work-life balance • Continuous learning and career development • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies