Utilization Review Clinician, RN, PT, OT

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate medical records to assess the necessity of medical services.

• Perform patient assessments.

• Oversee admissions and informational consultations.

• Ensure prompt post-discharge follow-ups with completed evaluations to minimize acute care readmissions.

• Review requests for post-acute services in accordance with established clinical guidelines and coverage criteria.

• Collaborate with physicians, healthcare professionals, and both internal and external stakeholders.

• Coordinate care with facilities and healthcare providers.

• Consult with peer reviewers, Medical Directors, or designated clinical reviewers.

• Conduct prior authorization and/or continued stay evaluations for post-acute care services.

• Approve services consistent with health plan regulations, contractual agreements, and criteria for medical necessity.

• Work with case managers, physicians, and medical directors to guarantee appropriate care levels and smooth transitions.

• Engage in team meetings, educational initiatives, and interrater reliability assessments.

• Ensure adherence to federal, state, and accreditation guidelines.

• Identify chances to improve communication or operational processes.

• Support payer programs and initiatives pertaining to the post-acute sector.

• Make determinations regarding benefits and appropriate care levels.

• Facilitate benefits and transitions across different care sectors.

• Utilize healthcare system resources to support physicians and patients.

• Perform additional job responsibilities as assigned.

⛳️ Requirements

• Bachelor’s degree or equivalent professional experience.

• 4-6 years of clinical nursing or therapy experience.

• Current RN, OT, or PT license.

• Proficient in Microsoft Office applications (e.g., Word, Excel).

• Comfortable using clinical decision support tools and operational software.

• Willingness to travel up to 30% based on business requirements.

• Flexibility to work additional or irregular hours as necessary.

• Must adhere to applicable security policies and procedures to protect company and client data.

• Ability to sit and view a computer screen for prolonged periods.

• Applicants for positions based in the U.S. must be legally authorized to work in the United States.

• Certain client-facing roles may necessitate compliance with specific requirements, such as immunizations and occupational health mandates.

• Preferred: 1-2 years of experience in utilization review, case management, and/or managed care regulations.

• Preferred: Familiarity with MCG Guidelines, InterQual, or other clinical decision support tools, particularly in utilization management and prior authorization processes.

🏝️ Benefits

• Comprehensive medical coverage including Rx, dental, and vision benefits.

• Mental health support through Employee Assistance Program (EAP).

• Generous paid time off, in addition to 13 paid holidays.

• 100% vested 401(K) retirement plans.

• Educational assistance of up to $2500 per year.