Pre-Payment Review Nurse Consultant- Wisconsin

Pre-Payment Review Nurse Consultant- Wisconsin

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.

Under the direction of the Nursing Administrator of the Clinical Program Integrity & Compliance Section, this highly responsible professional position must demonstrate sound clinical and professional judgment and work under general supervision. This position serves as an Office of Inspector General (OIG) Nurse Consultant for pre-payment activities. Responsibilities include conducting clinical and financial pre-payment compliance reviews to detect, combat, and eliminate fraud, waste, and abuse in the Medicaid program. Additional duties include consulting on the development and implementation of pre-payment review policies and guidelines that support OIG program objectives. The role requires the ability to perform comprehensive medical record reviews and analyze complex datasets and systems.

This position requires exceptional written and oral communication skills, strong problem-solving abilities, and clinical experience across multiple care settings with both pediatric and adult populations. The role also requires knowledge of federal and state regulations, Medicaid and Medicare programs, systems analysis, and research methods. This includes the ability to develop, establish, and implement pre-payment review criteria across multiple service areas, and to process pre-payment reviews according to medical necessity criteria, administrative code, and other requirements.

What we're looking for: Current Wisconsin Registered Nurse license issued by the Wisconsin Department of Safety and Professional Services. Knowledge of current medical concepts, practices, and techniques. Ability to assess statistical data and reports related to health service utilization patterns. Knowledge of laws, statutes, regulations, and rules related to the state Medicaid program. Knowledge of federal and state legislation pertaining to Title XIX, Title XVIII, Title XX, and Title III. Ability to incorporate medical knowledge and experience into the development of medical policy, administrative rules, and medical standards. Ability to develop standards and guidelines for monitoring medical practice patterns. Thorough knowledge of Medicaid-covered services and reimbursement policy for analysis, recommendation development, and implementation. Ability to use medical and financial records, claims, and claims data to obtain documentation supporting audit or investigative findings. Knowledge of Generally Accepted Auditing Standards (GAAS). Skill in using computer-accessible databases to support audit activities and technology used for pre-payment review audits, including reviewing and analyzing computer-generated reports. Extensive knowledge of hardware, software, and networking technologies relevant to healthcare industry changes. Knowledge of program, financial, and accounting systems used by healthcare entities, including patient account management, billing processes, and reimbursement procedures. Understanding of governmental and industry accounting and auditing standards or audit guides used to audit healthcare providers. Ability to organize, prepare, summarize, and present information gathered during audits or investigations in a clear and usable manner to support valid findings and conclusions. Extensive knowledge of technical writing, publication organization, preparation, and formatting. Ability to clearly express the State's position on Medicaid issues—both orally and in writing—in audit reports, investigative reports, exit conferences, and departmental meetings. Knowledge of records maintained by healthcare providers and the ability to inspect medical records, patient charts, financial statements, transaction documentation, invoices, payroll records, and claims.

What you should expect in this role: Position requires residency in the state of Wisconsin. Role is 100% remote. No travel obligations. Applications will be accepted until July 13, 2026. The pay range for this position is $86,000.00 - $105,000.00 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.