Gainwell Technologies

Data Scientist

• Designs, develops, programs methods, processes, and systems to consolidate and analyze unstructured, diverse big data sources using machine learning and predictive modeling tools
• Builds analytic models to identify and quantify solutions to business problems
• Interprets and communicates insights and findings from analysis and experiments to client, service, and business managers
• Determines probable future outcomes and recommends and delivers new business process improvements
• Provides leadership and work guidance to less experienced personnel towards build of software programs, algorithms and automated processes to cleanse, integrate and evaluate large datasets

Principal Data Scientist

Analyst

• Review and research suspended claims per DVHA guidelines.
• Refer claims to the appropriate department for further review when necessary.
• Process claim adjustments and corrections as needed.
• Prepare and issue Return to Provider (RTP) notices for incomplete or incorrect claims.
• Maintain and update claims resolution procedure documentation.
• Train backup or replacement staff as needed.
• Perform other duties as assigned.

Claims Resolution Analyst

• Design and build AI Solutions that use machine learning models, including GenAI, NLP, and predictive analytics solutions for healthcare applications
• Develop, test, and deploy AI solutions in cloud and on-premise environments, ensuring reliability, scalability, and real-world impact
• Work with large healthcare datasets, performing data preprocessing, feature engineering, and model training while ensuring compliance with HIPAA and other regulatory standards
• Implement and optimize AI solutions within Gainwell’s existing technology stack, collaborating with engineering teams to ensure seamless integration
• Continuously monitor, refine, and optimize AI solutions for accuracy, efficiency, and speed, leveraging MLOps best practices
• Stay updated with the latest AI/ML advancements, exploring new technologies and methodologies to enhance solution effectiveness
• Ensure AI implementations adhere to healthcare industry regulations, ethical AI principles, and data privacy standards
• Identify opportunities to automate workflows and optimize business processes using AI-driven solutions

Data Science AI Engineer – Advisor

Director

• Directs the organization and performance of certain functional areas and the activities of senior managers
• Provides staff direction with an understanding and following of established company policies and procedures
• Oversees business activities to ensure a high standard of professional excellence is maintained among staff members
• Directs business function including, approval of overall project plan, budgets, and work breakdown structure
• Establishes and implements short- and long-term strategies to deliver services to customers within reasonable schedules and budgets
• Establishes and communicates goals and objectives, defines methodologies, tasks, and activities, and clearly describes roles and responsibilities for performing to personnel
• Communicates broadly to help ensure overall coordination for cross-functional teams

Director of Technology

Consultant

• Support the Regional Provider Relations team by researching, investigating, documenting, and responding to provider and state partner inquiries within established response time standards
• Manage out-of-state and non-bordering Idaho provider concerns, including outreach, education, issue resolution, and follow-up
• Build and maintain professional relationships with healthcare providers, provider offices, associations, state partners, and operational teams
• Assist with the development and delivery of provider education materials through one-on-one support, virtual meetings, workshops, conferences, and group sessions
• Research claims, enrollment, credentialing, billing, compliance, and operational issues while identifying opportunities for workflow and process improvement

Provider Relations Consultant

Software Engineer

• Codes, tests, debugs, implements, and documents programs.
• Assists in the modification of company products and/or customer/internal systems to meet the needs of the client and/or end-user.
• Gathers information from the system, analyses program and time requirements, and prepares documentation to change existing programs.
• Researches and analyses existing systems and program requirements, under periodic supervision.
• Designs programs for projects or enhancements to existing programs.
• Writes specifications for programs of low to moderate complexity.
• Assists in resolving production support problems.
• Develops and suggests alternative approaches to resolving problems.
• Develops test plans to verify logic of new or modified programs.
• Identifies issues as appropriate.
• Creates appropriate documentation in work assignments such as program code, and technical documentation.
• Conducts quality assurance activities such as peer reviews.

C-Unix Developer

• support provider enrollment and provider revalidation operations by ensuring the accuracy, quality, and compliance of provider enrollment transactions, documentation, and operational processes.
• Conduct quality reviews and audits of provider enrollment applications, provider revalidations, maintenance requests, renewals, and supporting documentation to ensure accuracy, completeness, and compliance with CMS, ACA, state, and federal guidelines.
• Monitor operational quality standards, productivity trends, documentation accuracy, and workflow compliance while identifying deficiencies, root causes, and opportunities for process improvement.
• Review and evaluate provider-related communications, case documentation, and enrollment activities to ensure adherence to internal policies, operational procedures, and client service expectations.
• Prepare reports, analyze quality findings, communicate audit results, and collaborate with leadership to recommend corrective actions, training opportunities, and procedural enhancements.
• Support calibration sessions, quality initiatives, audits, training activities, and continuous improvement efforts while maintaining confidentiality and compliance with HIPAA and company security standards.

Provider Enrollment Quality Analyst

• Support provider enrollment and provider revalidation operations for Medicaid healthcare programs
• Review, process, and verify provider enrollment and provider revalidation applications for accuracy, completeness, and compliance with Medicaid and CMS guidelines
• Research, analyze, and resolve provider enrollment discrepancies by working with providers, internal departments, and external stakeholders while identifying potential fraud or inconsistent information
• Maintain accurate provider records within enrollment systems and perform quality audits, validation checks, and reporting activities to support operational accuracy and program integrity
• Interpret policies, procedures, and workflow requirements while supporting process improvements and updated standard operating procedures within a high-volume operational environment
• Handle confidential provider and healthcare information in accordance with HIPAA, company security standards, and regulatory compliance requirements while meeting productivity and quality expectations

Provider Enrollment Analyst

Account Manager

• Lead a team of Pharmacy Account Managers supporting multiple state Medicaid Pharmacy programs delivering consultative services with a high NPS and operational excellence.
• Provide strategic consultative pharmacy services to state Medicaid leadership advising them on all aspects of a Medicaid pharmacy benefit.
• Aligns with State Sector Leads and Account General Managers on client needs and VOC, partnering with Product and pharmacy leadership team.
• Assesses market trends, customer segments, and drives internal and external value proposition and message for GainwellRx.
• Partners with Pharmacy executive team in developing and delivering pharmacy market and solution training to state account teams.
• Aligns with Product team and Growth team for field campaigns, training, webinars, and client presentations.
• Drives new solution ideas, partners with states on new concepts, and works with product & engineering teams to deliver models to support them.
• Collaborates with Marketing on GainwellRx overall market message, media strategy, and GTM strategy.
• Supports state needs through RFP and bid proposals.
• Partners with Pharmacy executive team to drive business strategy and business development through market and competitive insights and analysis.
• Connect market insights into growth strategies and solution pipeline strategies.
• Drives key initiatives in support of strategy, pharmacy growth, and business development.
• Drives market analysis in support of business development projects and senior leadership key initiatives.
• Serves as an industry expert on GainwellRx, interfacing with external clients, vendors, and business partners.
• Collaborates across account teams, sales teams, product teams, and other shared service functions.

Senior Director, Rx Account Management

Project Manager

• assist in keeping projects moving to deliver better health and human services outcomes
• lead one or more large project management teams
• spearhead project planning, tracking and oversight of assigned staff
• communicate project metrics/status and recommend program changes
• create project schedules, program definitions, budgets and objectives
• prepare detailed SOW and assist with new proposal efforts and business development

Project Management Advisor

Call Center Representative

• Handle inbound calls from members and providers, delivering accurate information related to healthcare benefits, eligibility, and services.
• Research and resolve inquiries efficiently while following established procedures and compliance guidelines.
• Document customer interactions clearly and accurately in multiple systems during live calls.
• Meet performance expectations including quality standards, service levels, and productivity goals.
• Contribute to a collaborative team environment focused on delivering reliable and responsive support.

Call Center Healthcare Representative

Designer

• Head up technical teams and workstreams as you design, develop, test and install complex database applications software — with server, client and web components
• Keep the team on the same page by overseeing relationships between application architects and developers to ensure design requirements result in flexible, reusable system components
• Create more satisfied clients by writing highly complex design, coding and testing documentation that yields purpose-built technical products that meet real needs
• Shine as an SME in the areas of development, domain, application design and database methodologies and best practices
• Show your know-how as you provide clients with technical consulting on highly complex projects by refining existing apps and designing new application modules and components
• Exercise your expertise by mentoring and guiding less experienced application designers

Advisor Application Designer

Claims Specialist

• Assist the Claims Manager with day-to-day Claims Team operations
• Provide training and guidance to team members
• Resolve claims issues by researching claim situations
• Generate required client reporting and support audits
• Assist with special projects and related team goals
• Research and analyze paid and denied claims, POS system issues, and pricing discrepancies

Professional Claims Analyst

Manager

• Responsible for supervising the day-to-day prepay, post-pay, prior authorization, and medical record review activities of a multidisciplinary team of Coders, Clinical DRG Auditors, and Nurse Reviewers.
• Oversees and manages the daily operations of the team by leading, assigning work, ensuring productivity and quality metrics are achieved, and analyzing production and workflow/processes to increase efficiency and quality.
• Consistently demonstrates effective change management by communicating changes timely and effectively; building commitment and overcoming resistance; supporting those affected by change; monitoring transition and evaluating results.
• Responsible for oversight and hiring of staff, retaining top talent, performance management, coordinating training and education, and providing leadership and mentorship to staff to build and improve skills to provide best-in-class practices to enhance efficiency, quality, and customer satisfaction.
• Monitor aging inventory, workload, assignments, productivity, and quality to ensure service level agreements, contract deliverables, and timelines are met.
• Evaluate and analyze productivity, utilization, efficiency, finding rates, savings, appeal overturn rate, and reviews completed by staff to identify opportunities for process improvements.
• Meet with clients and providers to discuss complex cases, trend analysis, exit and/or settlement conferences.
• Serve as a Subject Matter Expert to assess new tools, automation, product development, and clinical readiness; act as a resource for resolving escalated issues, and coach and mentor staff to develop a high-performing team.
• Analyze reports and data and identify trends and resources that improve the delivery of clinical review services.
• Manage and evaluate individual/team performance and take appropriate action to meet and/or exceed performance standards.
• Perform other functions as assigned.

Associate Manager, Clinical Review

Artificial Intelligence

• Translate organizational objectives into actionable AI strategies and deliver scalable, results-oriented solutions.
• Oversee the end-to-end implementation of AI technologies, including GenAI models for applications such as claims processing, documentation automation, and customer support tools.
• Build and manage a high-performing team of AI engineers, data scientists, and product managers, ensuring accountability and alignment with project timelines.
• Collaborate with cross-functional teams to integrate AI capabilities into Gainwell’s existing systems and ensure their operational success.
• Monitor AI project performance and lead continuous improvement efforts to meet evolving client needs and regulatory requirements.
• Ensure all AI implementations comply with HIPAA, CMS, and other healthcare standards, prioritizing data security and ethical practices.
• Drive efficiency and cost-effectiveness by identifying opportunities to streamline workflows and processes using AI technologies.