Utilization Review Clinician – RN, PT, OT

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

📋 Description

• Evaluate medical records to ascertain medical necessity.

• Perform patient assessments, oversee admissions and information sessions, and guarantee timely follow-ups post-discharge with completed evaluations to mitigate acute care readmissions.

• Analyze requests for post-acute services leveraging established clinical guidelines and coverage criteria.

• Collaborate with physicians, healthcare professionals, and both internal and external stakeholders to enhance health outcomes.

• Coordinate care with facilities and providers throughout the medical management continuum.

• Consult with peer reviewers, Medical Directors, or designated clinical reviewers to ensure that care is medically suitable, high-quality, and cost-efficient.

• Conduct prior authorization assessments and/or ongoing stay reviews for post-acute care services.

• Escalate cases to medical directors when necessary.

• Approve services in alignment with health plan guidelines, contractual agreements, and criteria for medical necessity.

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

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

• Ensure adherence to federal, state, and accreditation standards while identifying opportunities for improved communication or processes.

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

• Make benefit decisions regarding suitable care levels based on clinical guidelines.

• Facilitate benefits and transitions across different care areas.

• Leverage healthcare-system resources to assist physicians and patients.

• Execute additional job responsibilities as required.

⛳️ Requirements

• Bachelor's degree or equivalent professional experience.

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

• Active RN, OT, or PT license.

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

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

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

• Comfortable utilizing clinical decision support tools and operational software.

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

• Available to work additional or unconventional hours as necessary.

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

• Capable of sitting and viewing a computer screen for extended periods.

• Candidates for U.S.-based positions with WellSky must be legally authorized to work in the United States.

• Certain client-facing roles may require compliance with relevant mandates, including immunizations and occupational health requirements.

🏝️ Benefits

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

• Mental health support via an Employee Assistance Program (EAP).

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

• 100% vested 401(K) retirement plans.

• Educational assistance up to $2500 annually.