Medical Expert

This is a fully remote position, open to applicants in Wisconsin.

📋 Description

• Assess and adjudicate prior authorization requests based on medical necessity, eligibility, and state policy regulations.

• Analyze clinical documentation and request additional information or clarification from healthcare providers.

• Input authorization decisions into the Medicaid Management Information System (MMIS).

• Act as a clinical subject matter expert and resource for healthcare providers, internal teams, and external stakeholders.

• Offer education and guidance to the provider community regarding prior authorization requirements and submission processes.

• Collaborate with leadership, operational teams, clinical colleagues, and state stakeholders to achieve program objectives.

• Identify opportunities for process improvements and suggest enhancements to the supported medical programs.

• Help review provider and member communications related to new or updated policies and procedures.

⛳️ Requirements

• Bachelor's degree in Nursing or a comparable combination of education and experience.

• Current RN license in Wisconsin, or an active RN license in another state with the capability to secure Wisconsin licensure before the start date.

• At least 5 years of nursing experience.

• Experience in Prior Authorization and/or Utilization Review.

• Preferred knowledge of Wisconsin Medicaid or other state Medicaid programs.

• Strong grasp of medical necessity review and clinical decision-making processes.

• Exceptional interpersonal, verbal, and written communication skills.

• Ability to interpret policies, procedures, and clinical documentation effectively.

• Strong organizational abilities with the capacity to manage priorities and meet deadlines independently.

• Experience in collaborating with cross-functional teams and stakeholders.

• Proficient in computer systems and technology utilized to support authorization and review processes.

• Must be available to work on weekends as required.

🏝️ Benefits

• Flexible hours.

• Work-life balance.

• Continuous learning and career development opportunities.

• Flexible vacation policy.

• 401(k) employer match.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.