Review Medicaid Prior Authorizations based on medical necessity in accordance with State policy guidelines
Provide guidance and support for Medicaid Providers
Act as a clinical SME (or liaison) for internal Gainwell entities
Adjudicating Durable Medical Equipment and prior authorizations based on medical necessity and eligibility
Reviewing and evaluating prior authorization submissions
Entering prior authorization outcome into the Medicaid Management Information System (MMIS) for processing
Participation in monthly meetings with Gainwell leadership, operational staff support, clinical peers and State stakeholders
Providing assistance and education to the provider community related to specific prior authorization submissions
Offering analysis and recommendations to Gainwell and State leadership on methods and potential process improvements.

Current Occupational Therapy, Physical Therapy or RN license in the state of WI
Extensive experience in the DME field, including both the provision, delivery and appropriate pricing and coding of durable medical equipment
Knowledge of and/or experience working with the Wisconsin Medicaid program
Excellent interpersonal, oral, and written communication skills
Ability to meet deadlines and manage priorities with minimal direct supervision.
Experience working with various partners or team members toward shared goals.

Durable Medical Equipment Consultant

Key skills