Pre-Payment Review Nurse Consultant

Gainwell Technologies

OIG Nurse Consultant at Gainwell overseeing Medicaid pre-payment activities. Conducting compliance reviews to combat fraud, waste, and abuse in the Medicaid program.

Posted 6/13/2026full-timeRemote • Wisconsin • 🇺🇸 United StatesMid-LevelSenior💰 $86,000 - $105,000 per yearWebsite

About the role

Key responsibilities & impact

Conducting clinical and financial pre-payment compliance reviews to detect, combat, and eliminate fraud, waste, and abuse in the Medicaid program.
Consulting on the development and implementation of pre‑payment review policies and guidelines that support OIG program objectives.
Perform comprehensive medical record reviews and analyze complex datasets and systems.
Develop, establish, and implement pre‑payment review criteria across multiple service areas.
Process pre‑payment reviews according to medical necessity criteria, administrative code, and other requirements.

Requirements

What you’ll need

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.

Benefits

Comp & perks

generous, flexible vacation policy
401(k) employer match
comprehensive health benefits
educational assistance
leadership and technical development academies

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical record reviewdata analysispre-payment reviewstatistical assessmentauditing standardstechnical writingmedical policy developmentreimbursement policy analysisclaims data analysishealth service utilization analysis

Soft Skills

organizational skillscommunication skillspresentation skillsanalytical skillsproblem-solving skills

Certifications

Wisconsin Registered Nurse license