Multiple Benefit Coverage - Registered Nurse

Title: Multiple Benefit Coverage- Registered Nurse- (Wisconsin)

Location:  Any city, WI, US, 99999

Req ID:  38091

Work Mode:  Please Select

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

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

In this role, you will help ensure Medicaid members receive appropriate services while supporting program integrity, quality outcomes, and compliance with state requirements. Key responsibilities include:

• 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.

What we're looking for

• 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.

What you should expect in this role

• 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.

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. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.