Personal Care RN

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

📋 Description

• Assess and make decisions on prior authorization requests by considering medical necessity, eligibility, and state policy regulations.

• Analyze clinical documentation and gather additional information or clarifications from healthcare providers.

• Record authorization decisions within the Medicaid Management Information System (MMIS).

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

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

• Work collaboratively with leadership, operational teams, clinical colleagues, and state stakeholders to achieve program goals.

• Identify areas for process enhancement and suggest improvements for supported medical programs.

• Assist in reviewing communications directed to providers and members concerning new or updated policies and procedures.

⛳️ Requirements

• Bachelor's degree in Nursing or an equivalent combination of education and experience.

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

• At least 5 years of nursing experience.

• Experience in Prior Authorization and/or Utilization Review.

• Familiarity with Wisconsin Medicaid or other state Medicaid programs is preferred.

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

• Exceptional interpersonal, verbal, and written communication skills.

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

• Excellent organizational skills with the capacity to manage priorities and meet deadlines autonomously.

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

• Proficient with computer systems and technologies that facilitate authorization and review processes.

• Willingness to work weekends as necessary.

🏝️ Benefits

• Flexible hours.

• Work-life balance.

• Opportunities for continuous learning and career development.

• Generous and flexible vacation policy.

• 401(k) employer match.

• Comprehensive health benefits.

• Educational assistance.

• Access to leadership and technical development academies.