Post-Acute Utilization Review Clinician

WellSky Administrative Services Corporation; United States; Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Excellent medical benefits

Mental Health support (EAP)

Paid time off + 13 holidays

401(k) retirement plan

Educational assistance

Job summary

WellSky Administrative Services Corporation in the United States is seeking an experienced Utilization Review Clinician to review medical records and determine medical necessity for post-acute services, coordinate with physicians and case managers, and ensure timely follow-ups.

The role requires a BS or equivalent, 4–6 years clinical nursing or therapy, active RN/OT/PT license, and comfort with decision support tools and MS Office.

Qualifications

• Bachelor’s degree or equivalent work experience.
• 4–6 years of clinical nursing or therapy experience.
• Active RN, OT, or PT license.
• Preferred: 1–2 years in utilization review, case management or managed care regulations.
• Experience with MCG Guidelines or InterQual is a plus.

Responsibilities

• Conduct prior authorization reviews and continued stay reviews for post-acute care using clinical guidelines.
• Approve services in line with health plan guidelines and medical necessity criteria.
• Collaborate with case managers, physicians and medical directors to ensure appropriate levels of care.
• Participate in team meetings and interrater reliability testing to maintain review quality.
• Ensure compliance with federal, state and accreditation standards and identify process improvements.
• Support payer programs and initiatives in the post-acute space.
• Make benefit determinations about appropriate levels of care using guidelines.
• Coordinate benefits and transitions between care settings.
• Use available healthcare resources to assist physicians and patients effectively.
• Perform other job duties as assigned.

Skills

Clinical nursing

Therapy experience

RN/OT/PT license

Microsoft Office

Education

Bachelor’s degree or equivalent

Tools

MCG Guidelines

InterQual

Clinical decision support tools

Microsoft Office

Job description

WellSky Administrative Services Corporation in the United States is seeking an experienced Utilization Review Clinician to review medical records and determine medical necessity for post-acute services, coordinate with physicians and case managers, and ensure timely follow-ups.

The role requires a BS or equivalent, 4–6 years clinical nursing or therapy, active RN/OT/PT license, and comfort with decision support tools and MS Office.