Physician Services RN Consultant

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 Physician Services RN Consultant will review Medicaid Prior Authorizations based on medical necessity in accordance with State policy guidelines, provide guidance and support for Medicaid Providers when appropriate, and act as a clinical SME (or liaison) for internal Gainwell entities. Note: This is not a patient facing position.

Your role in our mission

• Adjudicating Physician related prior authorizations based on medical necessity and eligibility, in accordance with State policy guidelines and accepted speech/language pathology practices.

• Reviewing and evaluating prior authorization submissions utilizing multiple computer systems, and when appropriate, seeking additional information or clarification from requesting provider.

• Entering prior authorization outcome into the Medicaid Management Information System (MMIS) for processing.

• Participation in any applicable meetings which include Gainwell leadership, operational staff support, clinical peers, and State stakeholders.

• Providing assistance and education to the provider community related to specific prior authorization submissions, when applicable.

• Offering analysis and recommendations to Gainwell and State leadership on methods and potential process improvements related to the administration and application of the Physician Services program.

• Review communications to providers and members on new/revised policies.

• Return provider phone messages.

• Summarize clinical information from PA documentation and provide an adjudication decision (e.g., approve, return, modify, or deny), as assigned. Support analytical work related to clinical assessments and policy development.

• Evaluate and develop clinical policy recommendations, develop/strengthen working relationships with Gainwell and DHS teams.

• Ability to manage multiple concurrent activities.

What we're looking for

• RN License in the State of Wisconsin
• Ability to make judgments in demanding situations.
• Ability to react to frequent changes in duties and volume of work.
• Ability to logically organize details.
• Comfortable accepting responsibility for medium to large scale projects involving multiple resources and spanning many months from start to finish.

What you should expect in this role

• This is a full-time position working Monday through Friday
• You will be working from home, but may be asked to come into a local Wisconsin office for meetings and other job related duties.
• In order to effectively work as a remote worker (work from home) with Gainwell, 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 or click here.  
• Video cameras must be used during all interviews, as well as during the initial week of orientation if hired.

 

 

 

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The pay range for this position is $76,900.00 - $109,900.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, fl