Multiple Benefit Coverage- Registered Nurse- (Wisconsin)

In this role, you will help ensure Medicaid members receive appropriate services while supporting program integrity, quality outcomes, and compliance with state requirements. Key responsibilities include:

• Reviewing and adjudicating prior authorization requests across multiple service areas based on medical necessity, eligibility requirements, and accepted clinical practices.
• Evaluating prior authorization submissions and obtaining additional information or clarification from providers when needed.
• Summarizing clinical information and rendering authorization decisions, including approvals, modifications, returns, or denials.
• Entering authorization outcomes into the Medicaid Management Information System (MMIS) for processing.
• Serving as a clinical subject matter expert and resource for providers, internal teams, and state stakeholders.
• Providing education and support to the provider community regarding authorization requirements and submissions.
• Participating in meetings with leadership, operational staff, clinical peers, and state partners.
• Supporting clinical policy development and providing recommendations for program and process improvements.
• Reviewing provider and member communications related to new or revised policies.
• Responding to provider inquiries and returning provider phone messages.
• Building and maintaining collaborative relationships with Gainwell and state agency partners.

• Active RN license in the State of Wisconsin.
• Experience reviewing prior authorizations and applying medical necessity criteria.
• Knowledge of Medicaid programs and healthcare policy guidelines.
• Strong clinical assessment and critical thinking skills.
• Ability to interpret clinical documentation and make sound coverage determinations.
• Excellent interpersonal, verbal, and written communication skills.
• Experience working with multiple computer systems and applications.
• Strong organizational skills with the ability to manage multiple priorities and concurrent activities.
• Ability to work independently and adapt to changing priorities and workloads.
• Experience collaborating with providers, internal teams, and external stakeholders.
• Ability to contribute to policy development, process improvement initiatives, and complex projects.

• Fully remote work environment.
• Fast-paced environment requiring strong critical thinking, organization, and attention to detail.
• Weekend hours may be flexible; however, candidates must be available to work weekends as needed to support operational requirements.
• This is not a patient-facing position.

Applications will be accepted through October 9, 2026.