About the position
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.
Bring your clinical expertise to a role that helps ensure members receive appropriate, high-quality healthcare services. As a Prior Authorization Utilization Review Nurse, you will review prior authorization requests, evaluate medical necessity, collaborate with providers and internal stakeholders, and support healthcare programs that improve outcomes while promoting responsible use of healthcare resources.
Responsibilities
• Review and evaluate prior authorization requests to determine medical necessity, appropriateness, and cost-effectiveness of services.
• Support access to quality care for members while ensuring compliance with program requirements and clinical guidelines.
• Serve as a clinical resource for providers, customers, and internal teams by resolving healthcare-related questions and concerns.
• Collaborate with providers, members, and internal stakeholders to facilitate timely and appropriate healthcare decisions.
• Interpret and apply complex clinical, regulatory, and procedural guidelines.
• Support utilization review and case management activities through clinical assessment and decision-making.
• Assist in the development and improvement of healthcare policies, provider communications, and program initiatives.
• Contribute to healthcare cost containment efforts while ensuring members receive appropriate, medically necessary care.
• Work independently while partnering with cross-functional teams to achieve program goals.
Requirements
• Bachelor's degree or equivalent combination of education and experience.
• Active, unrestricted RN or LPN license in the United States.
• Strong oral and written communication skills.
• Strong analytical, organizational, and time management skills.
• Ability to read, understand, and interpret complex regulatory and procedural documents.
• Proficiency with PC-based systems and applications.
• Ability to work independently with minimal supervision.
• Two or more years of Medicaid experience or other healthcare experience.
Nice-to-haves
• Previous experience supporting Utilization Review, Prior Authorization, Case Management, or Managed Care programs.
Benefits
• flexible vacation policy
• 401(k) employer match
• comprehensive health benefits
• educational assistance