Utilization Review Clinician (RN, OT, or PT) - Remote at WellSky

United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Bachelor's degree or equivalent work experience
4-6 years of clinical nursing or therapy experience
Active RN, OT, or PT license
Working knowledge of Microsoft Office applications (e.g., Word, Excel)
Comfortable using clinical decision support tools and operational software

Responsibilities

Review medical records to determine medical necessity
Conduct patient evaluations
Manage admissions and informational visits
Ensure timely post-discharge follow-ups with completed assessments
Review requests for post-acute services promptly, using established clinical guidelines and coverage criteria
Collaborate with physicians, healthcare providers, and stakeholders to support improved health outcomes
Coordinate care with facilities and providers
Follow standard operating procedures and organizational policies
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
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
Support all 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 knowledge of resources available in the healthcare system to assist physicians and patients
Perform other job duties as assigned

Skills

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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