Utilization Review Clinician

Employment Type: Full-time

Position Overview

This role is responsible for reviewing medical records to determine medical necessity. The scope of this job includes providing skilled nursing care to patients, completing patient evaluations, admissions, and informational visits. A key responsibility is ensuring post-discharge visits occur within specified timeframes following discharge, with post-discharge assessments completed to minimize potential acute care readmissions.

This position is responsible for the timely review of requests for post-acute services. Based on established clinical guidelines and/or coverage benefit limitations, the Utilization Review Clinician will determine the appropriateness of requested services. The clinician will comply with all standard operating procedures and all departmental and organizational policies. They will develop relationships with physicians, healthcare service providers, internal and external customers to help improve health outcomes for enrollees. The clinician will apply clinical knowledge to work with facilities and providers for care coordination. They will access and consult with peer clinical reviewers, Medical Directors, and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost-effective care throughout the medical management process.

We invite you to apply today and join us in shaping the future of healthcare!

Key Responsibilities

• Conduct prior authorization reviews and/or continued stay reviews for post-acute care services by applying clinical guidelines and escalating 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 to maintain review consistency and professional growth.
• Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes.
• 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 effectively.
• Perform other job duties as assigned.

Required Qualifications

• Education: Bachelor's Degree or equivalent work experience.
• Experience: 4-6 years of clinical nursing or therapy experience.
• Background Checks: Able to pass federal and state required criminal/abuse background checks and drug screen.
• Computer Skills: Including but not limited to MS Office, MS Excel, and Clinical/Operational Software.

Preferred Qualifications

• RN, PT, OT Compact License highly preferred.
• Experience in utilization review, case management, and/or managed care.
• Experience with MCG/Interqual or other criteria-based applications.
• General understanding of managed care guidelines and impact on services.
• Graduate of an accredited school of nursing or therapy.
• Minimum of 1-2 years of utilization management experience, case management, managed care regulations; or any combination of education and experience which would provide an equivalent background.

Job Expectations

• 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.

#LI-PG1 #LI-Remote

Company Information

WellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky, you can make a difference. WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gende