Gainwell Technologies develops digital and cloud-enabled solutions for the human services and public health ecosystem. The company works with clients across all 50 U.S. states on healthcare initiatives including Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions. Its work connects technology with public health delivery, healthcare administration, and efforts to improve health outcomes and community well-being.
Remote Associate Manager, Clinical Quality – Prior Authorization (Florida)
Lead prior authorization quality assurance for Gainwell Technologies’ healthcare programs, guiding clinical auditors and supporting compliant determinations. Improve review quality through performance monitoring, staff coaching, and targeted quality initiatives.
United States
Florida$71,500 – $102,100 / year
RemoteFull-timeMiddleEnglish RequiredClinical OperationsDescription
- Oversee the Prior Authorization quality review program, including its policies, procedures, and compliance controls.
- Build and maintain quality assurance processes, audit methods, and performance benchmarks for medical and behavioral health reviews.
- Lead and mentor clinical quality auditors and reviewers through training, coaching, and performance feedback.
- Track and report quality, accuracy, timeliness, productivity, denial rationale, and interrater reliability metrics.
- Spot trends, root causes, and improvement opportunities in clinical criteria use, documentation, review consistency, and workflows.
- Review audit results, appeals, complaints, and regulatory findings to identify issues and recommend corrective actions.
- Create leadership reports and dashboards covering performance, audit results, risks, and improvement efforts.
- Ensure Prior Authorization reviews are accurate, consistent, and completed within required timeframes.
- Develop and deliver training informed by audit findings, policy changes, and performance trends.
- Stay current on CMS and Medicaid requirements, accreditation standards, clinical policies, and industry practices.
- Lead initiatives to improve accuracy, consistency, efficiency, and provider and member experience.
- Advise on new tools, automation, operational readiness, and escalated quality concerns as a subject matter expert.
- Manage individual and team performance against established standards.
- Carry out other assigned duties.
Requirements
- Associate degree required; bachelor’s degree preferred.
- Current, unrestricted RN license required.
- Certification in utilization management, case management, or healthcare quality is preferred.
- Working knowledge of Prior Authorization, utilization management, medical necessity review, adverse determinations, and relevant regulatory and accreditation requirements.
- Ability to apply evidence-based clinical criteria, health plan policies, benefit requirements, and clinical judgment consistently and accurately.
- At least five years of experience in Prior Authorization, utilization management, clinical review, or healthcare quality assurance.
- At least two years of leadership or quality assurance experience in a health plan, managed care, utilization management, or healthcare setting.
- Strong analytical, communication, coaching, and problem-solving skills.
- Experience using quality data to drive measurable improvement.
Benefits
- Flexible hours and work flexibility.
- Work-life balance.
- Ongoing learning and career development.
- Flexible vacation policy.
- 401(k) with employer match.
- Comprehensive health benefits.
- Educational assistance.
- Leadership and technical development academies.
- Travel up to 20%.