Prior Authorization Utilization Review - PASRR (Remote Nurse)

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.

Summary

 The Prior Authorization Utilization Review Specialist - PASRR provides clinical expertise to staff, management and customer within a health care account. Act as liaison to customers, providers, and recipients by resolving problems and clarifying medical and healthcare issues. Recommend and promote beneficial changes to customer programs to promote access to quality care and control of benefit packages.

Your role in our mission

• Assist in adjudication of medically complicated claims.
• Participate in customer’s policy development. Provide assistance in drafting provider manuals, bulletins, and revisions to promote publication.
• Assist with organized healthcare groups and associations on various medical issues related to the State’s medical program.
• This clinician will be part of the Prior Authorization team. The team has the responsibility for the following: to review, assess, and pre-approve selected non-emergency medical services prior to the actual delivery.
• The clinician is to help with cost containment and utilization review measures to make payment for only those treatments and services that are medically necessary, appropriate, and cost effective.
• The clinician provides support to the case management functions by accepting treatment plans as a form of prior authorization.
• Other duties may be assigned as required.

What we're looking for

• Active nursing license (RN or LPN license) in the United States required with no license restrictions
• Minimum of two (2) years Medicaid experience or other health care experience preferred
• Knowledge of PASRR process preferred
• Strong oral and written/ communication skills. Ability to manage time and be organized in daily tasks
• Strong analytical skills to make medical necessity determinations based on regulatory and procedural documents

What you should expect in this role

• This is a full-time permanent regular salaried (W-2) employee position.
  • Monday through Friday work schedule (40 hours per week).
• Upward career advancement is possible and encouraged.
• Health (medical, dental, vision) and paid time off benefits start on day 1 of employment.
• Company match 401K and other benefits available within months of starting.
• Computer for work company-provided.
• For all hybrid and remote positions employees' Broadband Internet connections, should have a minimum speed of 24MBS download and 8 MBS upload.  Greater speeds will of course provide better performance.
  • To Test your internet download and upload speed:
    • Go to Google.
    • Search for Internet Speed Test.  
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