Registered Nurse – Multiple Benefit Coverage

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

📋 Description

• Assess and make decisions on Medicaid prior authorization requests across various service areas.

• Analyze prior authorization submissions and request further information or clarification from providers as necessary.

• Summarize clinical data and make authorization decisions, including approvals, modifications, returns, or denials.

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

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

• Offer education and support to providers regarding authorization protocols and submissions.

• Attend meetings with leadership, operational staff, clinical colleagues, and state partners.

• Assist in the development of clinical policies and suggest program and process enhancements.

• Review communications from providers and members concerning new or updated policies.

• Address provider inquiries and respond to provider voicemails.

• Cultivate and sustain collaborative relationships with Gainwell and state agency partners.

⛳️ Requirements

• Current RN license in the State of Wisconsin.

• Experience in reviewing prior authorizations and applying medical necessity criteria.

• Familiarity with Medicaid programs and healthcare policy guidelines.

• Strong clinical assessment and critical thinking abilities.

• Capability to interpret clinical documentation and make informed coverage decisions.

• Excellent interpersonal, verbal, and written communication skills.

• Proficiency in using multiple computer systems and applications.

• Strong organizational skills with the capacity to handle multiple priorities and simultaneous tasks.

• Ability to work independently and adapt to shifting priorities and workloads.

• Experience collaborating with providers, internal teams, and external stakeholders.

• Ability to contribute to policy formulation, process improvement initiatives, and complex projects.

• Must be available to work weekends as needed.

🏝️ 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.