Medical Advisor

Gainwell Technologies

. Review and adjudicate prior authorization requests based on medical necessity, eligibility, and state policy guidelines .

Posted 10/27/2026full-timeRemote • United StatesMid-LevelSenior💰 $90,900 - $129,900 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Prior Authorization and Utilization Review processes, with a strong understanding of medical necessity and clinical decision-making. Proficient in collaborating with cross-functional teams and providing education to the provider community regarding Medicaid policies.

Highest-signal resume keywords

Bachelor's Degree In NursingCurrent RN License In WisconsinPrior Authorization ExperienceUtilization Review ExperienceKnowledge Of Wisconsin Medicaid

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewClinical Decision-MakingPolicy InterpretationClinical Documentation EvaluationAuthorization Determination

Soft Skills

Excellent Communication SkillsStrong Organizational SkillsInterpersonal SkillsAbility To Manage PrioritiesCollaboration Skills

Tools & Technologies

Medicaid Management Information System (MMIS)Computer Systems Proficiency

Certifications & Qualifications

RN License

Industry Keywords

Prior AuthorizationUtilization ReviewMedicaid ProgramsProcess ImprovementProvider Education

About the role

Key responsibilities & impact

Review and adjudicate prior authorization requests based on medical necessity, eligibility, and state policy guidelines
Evaluate clinical documentation and obtain additional information or clarification from providers when needed
Enter authorization determinations into the Medicaid Management Information System (MMIS)
Serve as a clinical subject matter expert and resource for providers, internal teams, and external stakeholders
Provide education and guidance to the provider community regarding prior authorization requirements and submissions
Collaborate with leadership, operational teams, clinical peers, and state stakeholders to support program objectives
Identify opportunities for process improvements and recommend enhancements to supported medical programs
Assist with reviewing provider and member communications related to new or revised policies and procedures
Support Medicaid members in receiving appropriate, medically necessary services through accurate and timely reviews

Requirements

What you’ll need

Bachelor's degree in Nursing or an equivalent combination of education and experience
Current RN license in Wisconsin, or an active RN license in another state with the ability to obtain Wisconsin licensure prior to the start date
Minimum of 5 years of nursing experience
Prior Authorization and/or Utilization Review experience
Knowledge of Wisconsin Medicaid or other state Medicaid programs preferred
Strong understanding of medical necessity review and clinical decision-making
Excellent interpersonal, verbal, and written communication skills
Ability to interpret policies, procedures, and clinical documentation
Strong organizational skills with the ability to manage priorities and meet deadlines independently
Experience collaborating with cross-functional teams and stakeholders
Proficiency with computer systems and technology used to support authorization and review processes
Availability to work weekends as needed

Benefits

Comp & perks

Flexible hours
Work-life balance
Continuous learning and career development
Flexible vacation policy
401(k) employer match
Comprehensive health benefits
Educational assistance
Leadership and technical development academies
Fully remote work environment