Utilization Review Clinician – RN, PT, OT
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Job Description
Utilization Review Clinician reviewing post-acute care services and medical necessity for WellSky. Coordinating authorizations, transitions, and clinical reviews to improve healthcare outcomes.
Responsibilities:
- Review medical records to determine medical necessity
- Conduct patient evaluations, manage admissions and informational visits, and ensure timely post-discharge follow-ups with completed assessments to help prevent acute care readmissions
- Review requests for post-acute services using established clinical guidelines and coverage criteria
- Collaborate with physicians, healthcare providers, and internal and external stakeholders to support improved health outcomes
- Coordinate care with facilities and providers throughout the medical management process
- Consult with peer reviewers, Medical Directors, or delegated clinical reviewers to ensure care is medically appropriate, high-quality, and cost-effective
- Conduct prior authorization reviews and/or continued stay reviews for post-acute care services
- Escalate cases to medical directors as needed
- Approve services in compliance with health plan guidelines, contractual agreements, and medical necessity criteria
- Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care and seamless care transitions
- Participate in team meetings, educational activities, and interrater reliability testing
- Ensure compliance with federal, state, and accreditation standards and identify opportunities to enhance communication or processes
- Support payer programs and initiatives related to the post-acute space
- Make benefit determinations about appropriate levels of care using clinical guidelines
- Coordinate benefits and transitions between various areas of care
- Utilize healthcare-system resources to assist physicians and patients
- Perform other job duties as assigned
Requirements:
- Bachelor's degree or equivalent work experience
- 4-6 years of clinical nursing or therapy experience
- Active RN, OT, or PT license
- 1-2 years' experience in utilization review, case management and/or managed care regulations
- Experience with MCG Guidelines, InterQual or other clinical decision support tools, especially in utilization management and prior authorization processes
- Working knowledge of Microsoft Office applications (e.g., Word, Excel)
- Comfortable using clinical decision support tools and operational software
- Willing to travel up to 30% based on business needs
- Willing to work additional or irregular hours as needed
- Must work in accordance with applicable security policies and procedures to safeguard company and client information
- Must be able to sit and view a computer screen for extended periods of time
- Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States
- Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates
Benefits:
- Excellent medical with Rx, dental, and vision benefits
- Mental Health support through EAP
- Generous paid time off, plus 13 paid holidays
- 100% vested 401(K) retirement plans
- Educational assistance up to $2500 per year
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