Utilization Review Clinician - RN, PT, or OT - Remote

WellSky Administrative Services Corporation; United States; Remote; USD 70.000 - 90.000; Vollzeit

Benefits dieser Stelle

Excellent medical benefits

Mental Health support (EAP)

Paid time off + 13 holidays

401(k) retirement plan

Educational assistance

Zusammenfassung

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.

Qualifikationen

• 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.

Aufgaben

• 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.

Kenntnisse

Clinical nursing

Therapy experience

RN/OT/PT license

Microsoft Office

Ausbildung

Bachelor’s degree or equivalent

Tools

MCG Guidelines

InterQual

Clinical decision support tools

Microsoft Office

Jobbeschreibung

*This role will require the successful candidate to work the shift of Monday to Friday, 1pm to 10pm Central (2pm to 11pm Eastern). The Utilization Review Clinician is responsible for reviewing medical records to determine medical necessity. This includes conducting patient evaluations, managing admissions and informational visits, and ensuring timely post-discharge follow-ups with completed assessments to help prevent acute care readmissions. In this role, you will also review requests for post-acute services promptly, using established clinical guidelines and coverage criteria to assess appropriateness. You’ll collaborate with physicians, healthcare providers, and both internal and external stakeholders to support improved health outcomes. By applying clinical expertise, you’ll coordinate care with facilities and providers, follow standard operating procedures and organizational policies, and consult with peer reviewers, Medical Directors, or delegated clinical reviewers to ensure care is medically appropriate, high-quality, and cost-effective throughout the medical management process. The ideal candidate will have working knowledge of Microsoft Office applications (e.g., Word, Excel) and be comfortable using clinical decision support tools and operational software.

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

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

Preferred Qualifications

• 1-2 years' experience in utilization review, case management and/or managed care regulations
• Experience with MCG Guidelines, InterQual or other clinical decision support tools, especially in utilization management and prior authorization processes

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

Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky:

• Excellent medical with Rx, dental, and vision benefits
• Mental Health support through EAP
• Generous paid time off, plus 13 paid holidays
• 100% vested 401(K) retirement plans
• Educational assistance up to $2500 per year

WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law.

WellSky is proud to be a drug-free workplace.

Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire.

Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates.

Data Privacy Notice for Job Applicants and Teammates

WellSky is a technology company leading the movement for intelligent, coordinated care worldwide. Our next-level software, analytics, and services power better outcomes and lower costs for stakeholders across the health and community care continuum. In today’s value-based care environment, WellSky helps providers, payers, health systems, and community organizations solve tough challenges, improve collaboration for growth, harness the power of data analytics, and achieve better outcomes by further connecting clinical and social care.