[Hiring] Behavioral Health Utilization Review Specialist @Gainwell Technologies LLC

Role Description

Apply your expertise to adjudicate Behavioral Health prior authorizations based on medical necessity and eligibility, in accordance with State policy guidelines and accepted best practices. Specialty areas include:

• Substance Use Disorder Treatment
• Child and Adolescent Day Treatment
• Adult Mental Health Day Treatment
• In-Home Family Therapy

There are no direct patient interactions for this role; rather, you will provide utilization review and quality assurance.

Your role in our mission includes:

• Review and evaluate prior authorization submissions utilizing multiple computer systems, and when appropriate, seek additional information or clarification from requesting providers.
• Enter prior authorization outcomes into the Medicaid Management Information System (MMIS) for processing.
• Participate in monthly meetings with leadership, operational staff support, clinical peers, and State of Wisconsin stakeholders.
• Provide assistance and education to the provider community related to specific prior authorization submissions, when applicable.
• Offer analysis and recommendations on methods and potential process improvements related to the administration and application of medical programs that you support.
• Review communications to providers and members on new/revised policies.

Qualifications

• Master's degree in counseling, social work, marriage and family therapy or equivalent
• A minimum of 5 years clinical work experience
• Current LPC, LCSW, or LMFT license in the state of WI (or license from another state and ability to obtain WI license prior to position start date)
• CSAC or SAC license in the state of WI (CSAC preferred)
• Knowledge of and/or experience working with the Wisconsin Medicaid program (or other state’s Medicaid programs) desired
• Previous experience in Utilization Management-Review preferred
• Excellent computer skills
• Excellent interpersonal, oral, and written communication skills
• Ability to meet deadlines and manage priorities with minimal direct supervision
• Experience working with various partners or team members toward shared goals
• Ability to communicate effectively and interpret policies and procedures

Requirements

• 100% Remote home office
• Full-time position
• Applications will be accepted through November 2, 2026
• The pay range for this position is $90,900.00 - $129,900.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors

Benefits

• Generous, flexible vacation policy
• 401(k) employer match
• Comprehensive health benefits
• Educational assistance
• Leadership and technical development academies to help build your skills and capabilities