Authorization Management Clinical Reviewer

🕒 3 days ago

🌪️ Kansas – Remote

🌪️ Kansas – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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WellSky

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1980

⚕️ Healthcare Insurance

☁️ SaaS

🤖 Artificial Intelligence

💰 Private Equity Round on 2020-07

Healthcare Insurance • SaaS • Artificial Intelligence

WellSky is a leading healthcare technology company dedicated to improving healthcare and community care outcomes worldwide. By offering comprehensive software solutions and analytics, WellSky enables healthcare providers, payers, and community organizations to collaborate and enhance care quality and accessibility. Their focus spans intelligent care management, connected care networks, and transformative analytics, aiming to create more efficient, inclusive, and sustainable healthcare systems. WellSky addresses social determinants of health and emphasizes patient and family engagement, supporting care in various settings including home, long-term, and acute care.

📋 Description

• Review acute and post-acute authorizations for medical necessity using InterQual guidelines • Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care • 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 • Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively • Perform other job duties as assigned

🎯 Requirements

• Bachelor's Degree or equivalent work experience • Active RN License • At least 4-6 years relevant work experience • 2 years clinical acute nursing experience • 1-2 years' of hospital-based utilization management experience • Denials and Appeals experience (Preferred) • Experience with managed care and CMS standards (Preferred) • UM/CM Knowledge of ICD / CPT / DRG’s (Preferred) • Proficient in the use of window-based computer programs (Preferred)

🏖️ Benefits

• 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