Job Description

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

As 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.

Required Qualifications

• 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

Essential Functions

• 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

Position Overview

• 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

What you should expect in this role

• Remote within the U.S.

Applications for this posting will be accepted until January 12, 2026. 

The pay range for this position is $59,600.00 - $85,100.00 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, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies  is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. 

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