Gainwell Technologies

Nurse

• Review and evaluate prior authorization requests to determine medical necessity, appropriateness, and cost-effectiveness of services
• Support access to quality care 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 developing and improving healthcare policies, provider communications, and program initiatives
• Contribute to healthcare cost containment efforts while ensuring appropriate, medically necessary care
• Work independently while partnering with cross-functional teams to achieve program goals

Utilization Review Nurse

Human Resources

• Serve as a first point of contact for managers and employees on HR policies, procedures, programs, and general HR guidance
• Support employee relations matters, including employee concerns, issue resolution, performance documentation, and engagement initiatives
• Escalate complex employee-relations issues as appropriate
• Guide managers on foundational performance management practices, including goal setting, feedback conversations, and development planning
• Support recruiting coordination, onboarding, internal transfers, and workforce planning activities
• Ensure consistent application of HR policies and procedures and compliance with employment regulations
• Prepare and maintain HR documentation, records, and case notes
• Compile and analyze HR reports, dashboards, and metrics to support decision-making and identify workforce trends
• Partner with HR Centers of Excellence to deploy HR programs and initiatives
• Participate in process improvement initiatives and contribute ideas to enhance efficiency and employee experience
• Maintain current knowledge of HR best practices, employment law updates, and organizational policies
• Perform other duties and responsibilities as assigned

Human Resources Business Partner

Architect

• Lead end-to-end delivery of the Provider+ domain
• Translate business requirements into solution design, configuration, testing, and operational readiness
• Serve as the primary functional subject matter expert
• Coordinate with clients and cross-functional teams
• Lead requirements validation discussions and maintain requirement metadata
• Facilitate design sessions and coordinate configuration and system-behavior demonstrations
• Lead planning and execution of Provider+ configuration and custom build
• Oversee Enrollment, Maintenance, and Revalidation configuration
• Support system integration testing, user acceptance testing, defect resolution, and user questions
• Maintain traceability from functional requirements through go-live readiness
• Manage RAID items and decision logs
• Coordinate across Product, AD&I, Testing, Training, and Technical teams
• Provide domain input to operational readiness reviews with the client
• Support parallel and performance testing spanning UAT and ORR

Lead Principal Application Architect

Support Engineer

• Support technical execution for MMIS and/or Medicaid Pharmacy environments
• Develop, maintain, and optimize complex SQL queries, views, and stored procedures
• Perform data analysis and root-cause investigations for system and production issues
• Extract, analyze, reconcile, and validate data across environments
• Support performance tuning by analyzing queries, batch jobs, execution plans, and system throughput
• Validate converted and migrated data
• Support and validate configuration synchronization from baseline to upper environments
• Analyze and reconcile interface outputs, extract files, reports, and database feeds
• Validate X12 EDI transactions including 834, 837, 835, 820, and 999/277
• Translate functional requirements into technical specifications and solution models
• Analyze and document data flows, integration logic, and technical dependencies
• Perform feasibility analysis for requested features
• Support SIT, UAT, parallel testing, and performance testing
• Assist with test data setup, environment readiness, validation scripts, and reconciliation
• Analyze defects and implement and validate fixes
• Support deployment, cutover, hypercare, and post-production issue resolution
• Serve as a technical liaison among business analysts, configuration analysts, developers, QA, conversion teams, and operations
• Document and communicate technical findings, risks, root causes, and resolutions
• Collaborate on data mappings and configuration validation
• Mentor junior technical analysts

Technical Analyst / Advisor, Application Architect

Program Manager

• Lead Fraud, Waste & Abuse (FWA) and Program Integrity initiatives from strategy through implementation, ensuring regulatory compliance and operational excellence
• Drive cross-functional collaboration to design, deploy, and optimize processes, systems, controls, and governance frameworks
• Analyze claims, provider, member, and audit data to identify fraud trends, billing anomalies, financial risks, and recovery opportunities
• Partner with analytics teams to develop detection strategies, business rules, dashboards, and investigative workflows
• Oversee testing, quality assurance, and user acceptance activities to ensure solutions meet business and compliance requirements
• Support audits and investigations through data analysis, documentation review, evidence gathering, and actionable recommendations
• Identify operational risks and process improvement opportunities to strengthen program effectiveness and outcomes
• Prepare executive-level reports and insights on program performance, audit findings, investigation results, and emerging risks
• Provide leadership, mentorship, and subject matter expertise to analysts, auditors, investigators, and implementation teams
• Serve as a trusted partner to clients, regulators, vendors, and internal stakeholders, driving accountability and continuous improvement

Program Manager, Fraud, Waste and Abuse

Customer Support

• Assist in keeping projects moving as Gainwell helps clients deliver better health and human services outcomes through technology and innovation
• Lead one or more large project management teams by breaking down larger technological programs and assisting with project staffing
• Spearhead project planning, tracking and oversight of assigned staff by providing direction and deadlines
• Communicate with client, company and project team leadership; measure and share project metrics and status; recommend program changes
• Create project schedules, program definitions, budgets and objectives across all project phases
• Project manage across non-direct reports by escalating risks and implementing mitigation solutions
• Prepare detailed SOWs and assist with new proposal efforts and business development

Project Manager – Customer Experience Operations

Technical Writer

• Research, write, edit, and proofread technical data for manuals, procedures, and specifications
• Write, organize, enter, and compile online help files supporting end users
• Create, compile, and deliver system/software development documentation packages
• Produce narratives, logic diagrams, input and output samples, input preparation instructions, and job setup information
• Use technical project team inputs, system requirements analyses, system design specifications, technical procedure development, configuration control requirements, test and training specifications, and programming notes
• Participate in quality reviews of various artifacts

Technical Writer – Early Career

Call Center Representative

• Oversee multiple contact center operations across all customer interaction channels
• Lead managers and supervisors to achieve service levels, customer satisfaction, quality standards, and business objectives
• Identify and implement operational process improvements
• Develop and manage volume forecasts, staffing models, and capacity plans
• Identify operational risks and performance gaps and implement mitigation strategies
• Collaborate with cross-functional teams to align resources with customer demand and organizational priorities
• Develop and manage operating, labor, technology, and departmental budgets
• Monitor financial performance, analyze budget variances, and implement corrective actions
• Oversee budget forecasting, financial analysis, resource allocation, and productivity initiatives
• Approve expenditures and operational investments
• Build partnerships with clients, business leaders, and operational stakeholders
• Lead customer experience improvement initiatives
• Ensure programs, projects, and service initiatives are delivered on time and within scope
• Partner with technology, workforce management, training, quality, and business teams on new services and operational enhancements
• Support business development activities, client presentations, operational solution design, and technology adoption
• Recruit, select, and retain managers, supervisors, and support staff
• Provide leadership, coaching, mentoring, and development opportunities
• Manage performance through goal setting, coaching, recognition, accountability, promotions, compensation adjustments, and succession planning

Senior Call Center Manager

Manager

• Provide strategic leadership and oversight for multidisciplinary teams of physicians, nurses, and clinical review professionals responsible for medical necessity determinations, utilization management, and clinical quality reviews
• Ensure compliance with regulatory, accreditation, contractual, and organizational requirements
• Identify, develop, and implement process improvements to improve clinical review quality, consistency, efficiency, and turnaround time
• Forecast workload demand and ensure adequate staffing and resource allocation
• Monitor clinical review volume, productivity, quality metrics, and service-level performance, implementing corrective actions as needed
• Develop strategic initiatives to improve medical review outcomes and provider satisfaction
• Manage operating, staffing, and departmental budgets
• Oversee workforce planning, recruitment, retention, succession planning, and professional development
• Manage relationships with clients, providers, and internal stakeholders
• Ensure timely and accurate delivery of medical review services
• Implement new programs, technologies, clinical guidelines, and service offerings
• Participate in business development, proposal development, operational planning, and presentations
• Recruit, select, and retain physicians, nurses, pharmacists, and other clinical professionals
• Provide leadership, coaching, mentoring, and performance management
• Evaluate employee performance and clinical review quality and address performance concerns

Senior Medical Review Manager

Representative

• Build and maintain strong working relationships with healthcare providers and provider organizations within an assigned California territory
• Conduct virtual and onsite provider visits to provide education, training, operational support, and assistance with Medi-Cal program requirements
• Develop and deliver provider training through workshops, seminars, webinars, one-on-one sessions, and other virtual and in-person educational events
• Provide one-on-one billing support and research healthcare claims, payment, and provider-related issues
• Serve as a liaison between healthcare providers, provider associations, internal Gainwell departments, and client representatives
• Apply established Medi-Cal policies, procedures, and program requirements to research and resolve provider questions and operational issues
• Identify provider trends, recurring issues, and opportunities for additional education or process improvement and communicate findings to leadership
• Exercise independent judgment within established guidelines while escalating complex or sensitive issues as appropriate
• Travel throughout the assigned geographic region for provider visits, training, outreach activities, provider association events, and other business needs
• Represent Gainwell professionally during provider meetings, training sessions, and outreach activities

Provider Field Representative

Supervisor

• Supervise Provider Field Representatives conducting provider outreach, education, training, and relationship-management activities throughout California
• Plan, assign, and monitor provider outreach activities, field visits, training sessions, presentations, and team deliverables
• Identify provider education and training needs
• Help develop outreach strategies, educational materials, presentations, and other resources
• Serve as an escalation resource for complex provider questions and operational issues
• Partner with internal teams and client stakeholders to research and resolve concerns
• Monitor provider outreach activities, team performance, field coverage, training effectiveness, and operational measures
• Provide regular updates and reporting to leadership
• Lead, coach, train, and develop employees
• Manage performance and support professional development
• Evaluate provider feedback, operational trends, and existing processes to identify improvement opportunities
• Support provider visits, outreach activities, training sessions, meetings, and other business needs as required
• Represent Gainwell during provider meetings, training sessions, and outreach activities
• Manage multiple priorities, territories, outreach activities, and operational requirements

Provider Outreach & Education Supervisor

Financial Planning and Analysis

• Supervise Financial Cash Control operations, including accounts receivable, EFT enrollment and maintenance, refunds, financial correspondence, and related financial transactions
• Lead, coach, train, and develop employees
• Manage daily workflow, assignments, productivity, quality, performance, and established service-level requirements
• Oversee financial requests tracked through CRM systems and financial adjustments processed through MMIS financial applications
• Research and resolve complex financial issues involving clients, providers, members, accounts receivable, payments, refunds, EFT, and related transactions
• Partner with clients, Claims, Information Technology, and internal teams to identify requirements, resolve operational issues, support system changes, and improve financial processes
• Analyze workflows and recommend improvements to increase accuracy, efficiency, consistency, compliance, and service delivery
• Manage priorities and deadlines while maintaining accuracy, quality, service levels, and compliance with Medi-Cal and organizational requirements
• Handle confidential financial, member, provider, client, and company information in accordance with privacy, security, and regulatory requirements

Financial Cash Control Supervisor

• Coordinate and support weekly Accounts Receivable operations
• Prepare the checkwrite for submission to DHCS and the State Controller’s Office
• Research, analyze, and resolve complex accounts receivable and financial issues
• Resolve escalated inquiries involving Gainwell, DHCS, providers, or other stakeholders
• Review and validate accounts receivable transactions and AR Master File activity
• Perform quality control to ensure accuracy, balancing, and successful completion of system-generated processes
• Process and support high-volume accounts receivable transactions for Medi-Cal programs
• Generate management and payment reports
• Coordinate quality assurance review activities
• Provide procedural guidance, onboarding and training, and workflow support
• Assist with complex financial transactions and issues
• Partner with DHCS, Gainwell teams, vendors, and other stakeholders through meetings, directives, procedural updates, system changes, testing, and operational initiatives
• Manage multiple priorities and deadlines while maintaining compliance requirements

Financial Cash Control Team Lead

Team Lead

• Monitor suspended claims inventories and help prioritize aging claims to meet turnaround times and service level requirements
• Review, research, price, process, and resolve suspended claims according to Medi-Cal guidelines, policies, and procedures
• Provide day-to-day guidance, training, and operational support to Claims Examiners
• Assist with complex claims and questions
• Track team productivity, quality, claims inventory, and other operational metrics
• Communicate potential issues or trends to the Claims Suspense Supervisor
• Identify workflow, quality, and processing issues
• Support improvements to claims accuracy, productivity, and operational performance
• Serve as backup to the Claims Suspense Supervisor
• Help coordinate daily team activities and priorities

Claims Suspense Team Lead

Business Analyst

• Analyze business challenges and help create technologies and solutions for health and human services outcomes
• Collaborate with business analysts to make client recommendations that improve business processes
• Translate client business needs and technical requirements into simpler non-technical language
• Analyze and document systems requirements and business processes
• Build basic conceptual data and process models to quantify potential system-change impacts
• Execute and analyze basic test case scenarios from existing test plans
• Participate in technical reviews and inspections with senior leaders
• Develop technical skills in Microsoft Excel, SQL, and Visio