Job Description

Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at HMS , a Gainwell Company carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You’ll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance. We also have comprehensive leadership and technical development academies to help build your skills and capabilities.

Summary:

We are seeking a skilled Registered Nurse with a Behavioral Health background to provide clinical expertise to staff, management, and customers within a health care account. Gainwell conducts prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines. This involves reviewing medical documentation, accurately documenting findings, and ensuring policy compliance.

Your role in our mission:

• Must be able to work under minimal direction, to complete assigned tasks. 
• Function as liaison to customers and providers by resolving problems and clarifying medical and healthcare issues. 
• Participate in customer’s policy development. 
• Provide clinical expertise in drafting provider manuals. 
• This clinician will be part of the Service Authorization team. The team is responsible for reviewing, assessing, and making decisions on behavioral health services based on medical necessity.
• The clinician is to help with cost containment and utilize review measures to make payment for only those treatments and services that are medically necessary, appropriate, and cost effective. 
• Other duties may be assigned as required.

What we’re looking for:

• Bachelor’s degree required.
• Minimum of two (2) years Medicaid experience or other health care payor/auditing experience preferred.
• Active LCSW, LMFT, or LPC license required (Alaska license preferred).
• Ability to make behavioral health service authorization determinations for medical necessity. 
• Strong time management and communication (oral/written) skills, with the ability to read, understand, and interpret complex regulatory and procedural documents, while utilizing a PC.
• Strong analytical skills.

What you should expect in this role:

• This is a full-time position.
• The work environment is office-based, with collaboration across clinical and operational teams.
• Preferred Location: Candidates based in Alaska are preferred due to the hybrid nature of the role (some in-office presence is required).
• Remote Option: Qualified candidates located in other U.S. states may also be considered for a fully remote arrangement.

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#LI-REMOTE

The pay range for this position is $69,100.00 - $98,700.00 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 HMS , a Gainwell Company . 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 HMS , a Gainwell Company , an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about HMS , A Gainwell Technologies Company at our  company website and visit our  Careers site for all available job role openings.

HMS, a Gainwell Company,  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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