Utilization Review Clinician: Care Coordination & Outcomes

WellSky; Chicago (IL); Remote; USD 75,000 - 105,000; Full time

Benefits offered by this job

Excellent medical benefits

Mental Health support through EAP

Generous PTO and 13 paid holidays

100% vested 401(K) retirement plans

Educational assistance

Job summary

WellSky is seeking a proactive Utilization Review Clinician to review medical records for medical necessity, coordinate post-acute care, and ensure timely follow-ups to prevent readmissions. You will apply clinical guidelines and collaborate with providers to determine appropriate care levels.

The role requires RN/OT/PT licensure and 4-6 years of clinical experience, plus comfort with Microsoft Office and decision-support tools; travel up to 30% may be required.

Qualifications

• Bachelor's degree or equivalent work experience.
• 4-6 years of clinical nursing or therapy experience.
• Active RN, OT, or PT license.

Responsibilities

• Conduct prior authorization reviews and continued stay reviews for post-acute care services using clinical guidelines.
• Approve services in compliance 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 reliability testing to maintain review consistency.
• Ensure compliance with federal, state, and accreditation standards and identify process improvements.
• Support payer programs and initiatives related to the post-acute space.
• Make benefit determinations about appropriate levels of care using guidelines.
• Coordinate benefits and transitions between areas of care.
• Utilize resources in the healthcare system to assist physicians and patients.
• Perform other job duties as assigned.

Skills

Clinical nursing

Therapy experience

Communication

Education

Bachelor's degree or equivalent work experience

Tools

MCG Guidelines

InterQual

Job description

WellSky is seeking a proactive Utilization Review Clinician to review medical records for medical necessity, coordinate post-acute care, and ensure timely follow-ups to prevent readmissions. You will apply clinical guidelines and collaborate with providers to determine appropriate care levels.

The role requires RN/OT/PT licensure and 4-6 years of clinical experience, plus comfort with Microsoft Office and decision-support tools; travel up to 30% may be required.