Utilization Review Specialist- Clinical Reviewer

Gainwell Technologies LLC

8d•Remote

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. SummaryAs a Utilization Review Specialist- Clinical Reviewer at Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve — a community’s most vulnerable. Connect your passion with purpose, teaming with people who thrive on finding innovative solutions to some of healthcare’s biggest challenges. Here are the details on this position.

Requirements

Bachelor’s degree or equivalent work experience or combination of education and experience
Minimum of two years Medicaid experience or other health care experience preferred
Active license as RN or LPN in the United States
Ability to make prior authorization determination
Strong oral/written communication skills
Ability to read, understand, and interpret complex regulatory and procedural documents
PC skills
Demonstrates strong writing skills
Time management and organizational skills
Ability to work independently without frequent supervision
Strong analytical skills
Ability to successfully interact with other departments

Responsibilities

Provide clinical expertise to staff, management, and customers with minimal direction
Act as a liaison between customers, providers, and recipients to resolve issues and clarify healthcare matters
Recommend and promote program improvements to enhance access to quality care and manage benefit packages
Assist in adjudicating medically complex prior authorizations
Participate in customer policy development
Support drafting and revising provider manuals, bulletins, and related publications
Collaborate with healthcare groups and associations on state medical program issues
Serve as part of the Prior Authorization team reviewing and pre-approving selected non-emergency services
Support cost containment and utilization review to ensure services are medically necessary, appropriate, and cost-effective
Perform additional related duties as assigned