Medical Expert

Gainwell Technologies

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

Posted 10/27/2026full-timeRemote • Wisconsin • 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

Prior Authorization ExperienceUtilization Review ExperienceRN License in WisconsinNursing ExperienceKnowledge of Wisconsin Medicaid

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewClinical Documentation EvaluationAuthorization Determination EntryPolicy InterpretationProcess Improvement Identification

Soft Skills

Interpersonal CommunicationOrganizational SkillsVerbal CommunicationWritten Communication

Tools & Technologies

Medicaid Management Information SystemComputer Systems Proficiency

Certifications & Qualifications

Bachelor's Degree in NursingCurrent RN License

Industry Keywords

State Policy GuidelinesProvider Community EducationCross-Functional CollaborationStakeholder Engagement

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
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 process improvement opportunities and recommend enhancements to supported medical programs
Assist with reviewing provider and member communications related to new or revised policies and procedures

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
Must be available 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