[Hiring] Multiple Benefit Services RN Consultant @Gainwell Technologies LLC

Role Description

As a Multi Benefit Services RN Consultant, you will leverage your clinical expertise to review Medicaid prior authorization requests and determine medical necessity in accordance with State policy guidelines. In this role, you will support providers, collaborate with internal stakeholders, and contribute to the delivery of high-quality, cost-effective healthcare services through accurate and timely clinical reviews.

Your role in our mission includes:

• Reviewing and adjudicating prior authorization requests across multiple service areas based on medical necessity, eligibility requirements, and accepted clinical practices.
• Evaluating prior authorization submissions and obtaining additional information or clarification from providers when needed.
• Summarizing clinical information and rendering authorization decisions, including approvals, modifications, returns, or denials.
• Entering authorization outcomes into the Medicaid Management Information System (MMIS) for processing.
• Serving as a clinical subject matter expert and resource for providers, internal teams, and state stakeholders.
• Providing education and support to the provider community regarding authorization requirements and submissions.
• Participating in meetings with leadership, operational staff, clinical peers, and state partners.
• Supporting clinical policy development and providing recommendations for program and process improvements.
• Reviewing provider and member communications related to new or revised policies.
• Responding to provider inquiries and returning provider phone messages.
• Building and maintaining collaborative relationships with Gainwell and state agency partners.

Qualifications

• Active RN license in the State of Wisconsin.
• Experience reviewing prior authorizations and applying medical necessity criteria.
• Knowledge of Medicaid programs and healthcare policy guidelines.
• Strong clinical assessment and critical thinking skills.
• Ability to interpret clinical documentation and make sound coverage determinations.
• Excellent interpersonal, verbal, and written communication skills.
• Experience working with multiple computer systems and applications.
• Strong organizational skills with the ability to manage multiple priorities and concurrent activities.
• Ability to work independently and adapt to changing priorities and workloads.
• Experience collaborating with providers, internal teams, and external stakeholders.
• Ability to contribute to policy development, process improvement initiatives, and complex projects.

Requirements

• Fully remote work environment.
• Fast-paced environment requiring strong critical thinking, organization, and attention to detail.
• Weekend hours may be flexible; however, candidates must be available to work weekends as needed to support operational requirements.
• This is not a patient-facing position.
• Applications will be accepted through October 9, 2026.

Benefits

• Pay range: $90,900.00 - $129,900.00 per year, with variations based on geographic region, internal equity, job-related knowledge, skills, and experience.
• 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.