[Hiring] Prior Authorization Registered Nurse Consultant @Gainwell Technologies LLC

Role Description

As a Prior Authorization Registered Nurse Consultant - Personal Care Services, you will apply your clinical expertise to review prior authorization requests and determine medical necessity for Personal Care Services and Private Duty Nursing within Medicaid programs. In this remote role, you will support providers and stakeholders by ensuring authorization decisions align with state policy guidelines, clinical standards, and program requirements while contributing to high-quality care delivery.

Your role in our mission:

• 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.

Qualifications

• 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 to achieve shared goals.
• Proficiency with computer systems and technology used to support authorization and review processes.

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.

Benefits

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