Utilization Review Clinician

United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

Candidates must possess a Bachelor's Degree or equivalent work experience and 4-6 years of clinical nursing or therapy experience. An RN, PT, or OT Compact License is required, along with the ability to pass federal and state criminal/abuse background checks and drug screens. Preferred qualifications include experience in utilization review, case management, managed care, and familiarity with MCG/Interqual or similar criteria-based applications. Proficiency in MS Office, MS Excel, and Clinical/Operational Software is necessary. Candidates must also be willing to travel up to 10% and work additional or irregular hours as needed, while adhering to security policies.

Responsibilities

The Utilization Review Clinician will conduct timely reviews of post-acute service requests using clinical guidelines and coverage limitations to determine service appropriateness. They will build relationships with healthcare providers and clients to enhance enrollee health outcomes, apply clinical knowledge for care coordination with facilities and providers, and consult with peer reviewers and Medical Directors to ensure medically appropriate, quality, and cost-effective care. Key duties include performing prior authorization and continued stay reviews, approving services in compliance with guidelines, collaborating with case managers and physicians for appropriate care levels and transitions, participating in team meetings and educational activities, ensuring compliance with federal, state, and accreditation standards, supporting payer programs, making benefit determinations, coordinating benefits and transitions, and utilizing knowledge of healthcare system resources.

Skills

Clinical Guidelines

Prior Authorization

Care Coordination

Medical Necessity

Health Plan Guidelines

Case Management

Communication

Process Improvement

WellSky

Healthcare software and community care solutions

About WellSky

WellSky offers software and services to improve health and community care, making it easier for providers and patients to access and navigate care. Its products, like the WellSky Value Based Care Suite, integrate with Electronic Health Record (EHR) systems to enhance care coordination. WellSky stands out by providing a comprehensive range of solutions, including strategic consulting and revenue cycle management, which help clients operate more efficiently. The company's goal is to enhance care delivery and improve individuals' quality of life through effective solutions.

Reston, VirginiaHeadquarters

1980Year Founded

$34.5MTotal Funding

DEBTCompany Stage

Social Impact, HealthcareIndustries

1,001-5,000Employees

Benefits

High deductible health plan with a generous employer contribution

PPO medical plan

Dental and vision insurance

401(k) plan with access to financial advisors who can provide personal financial guidance at no cost

Robust paid time off, including holidays, vacation, well-being, and volunteer days

Flexible spending accounts (medical and dependent)

Life and disability insurance

Educational assistance

Employee Assistance Plan with free and confidential emotional, financial, legal, and family resources

Risks

Integration challenges with acquisitions like Bonafide may cause operational inefficiencies.

Data privacy issues may arise from collaborations in the nonprofit sector.

Dependency on third-party systems increases exposure to partners' operational risks.

Differentiation

WellSky offers comprehensive solutions across the full continuum of care.

The company integrates with any EHR system to improve care coordination.

WellSky's services include strategic consulting, compliance, and revenue cycle management.

Upsides

Growing demand for integrated care solutions boosts WellSky's market potential.

Value-based care models align with WellSky's offerings, enhancing growth opportunities.

Acquisitions like TapCloud enhance patient engagement and reduce costs.

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