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Gainwell Technologies · 1 day ago

Utilization Review Specialist- Clinical Reviewer

United States

Full-time

Remote

Entry, Mid Level

$60K/yr - $85K/yr

2+ years exp

Gainwell Technologies is focused on solving complex challenges in healthcare. As a Utilization Review Specialist- Clinical Reviewer, you will leverage your clinical expertise to support prior authorization processes and improve access to quality care while collaborating with various stakeholders in the healthcare system.

Health CareInformation Technology

Responsibilities

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

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

Qualification

Medicaid experienceActive RNLPN licensePrior authorization determinationAnalytical skillsComplex regulatory interpretationPC skillsInterdepartmental interactionOral communicationWritten communicationTime managementOrganizational skillsIndependent work