Authorization Management Clinical Reviewer – Appeals and Denials

🔥 1 minute ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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WellSky

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1980

🏥 Healthcare

💼 Consulting

📦 Logistics

💰 Private Equity Round on 2020-07

Healthcare • Consulting • Logistics

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 authorization requests and medical records to evaluate medical necessity using established clinical guidelines • Manage medical necessity denials from initial notification through final resolution • Apply acute-care clinical knowledge, payer requirements, and medical necessity criteria to determine appropriate resolution paths • Ensure timely follow-up and escalation of denials • Review clinical documentation, payer policies, and medical necessity criteria to develop comprehensive, evidence-based appeals within established deadlines • Identify denial trends, root causes, and process improvement opportunities to reduce preventable denials and improve reimbursement outcomes • Collaborate with physician advisors, utilization review nurses, hospital stakeholders, physicians, healthcare providers, and internal and external stakeholders • Determine appropriate appeal strategies, including peer-to-peer reviews, reconsiderations, and formal appeals • Review acute and post-acute authorizations 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 • Ensure compliance with federal, state, and accreditation standards • Utilize healthcare-system resources to assist physicians and patients effectively • Perform other job duties as assigned

🎯 Requirements

• Strong acute-care clinical background with the ability to apply evidence-based guidelines • Proficiency with technology solutions, including Microsoft Office and utilization management support tools • Familiarity with CarePort Care Management preferred • Licensed RN, with the ability to obtain other clinical state licensures, as needed • Bachelor's Degree or equivalent work experience • Active RN License • At least 4-6 years relevant work experience • At least 3 years of denial management experience in an acute hospital setting, including development and submission of medical necessity appeals • 2 years clinical acute nursing experience • 1-2 years of hospital-based utilization management experience • Experience with managed care and CMS standards preferred • Experience collaborating with physician advisors on peer-to-peer reviews, reconsiderations, and formal appeals preferred • UM/CM knowledge of ICD, CPT, DRGs, and hospital revenue cycle workflows preferred • Proficient in the use of window-based computer programs preferred • Excellent verbal, written, and interpersonal communication skills preferred • Critical thinking, creative problem solving, organization, and planning skills preferred • Experience with InterQual guidelines for acute-care and/or other clinical decision support tools, especially in utilization management and prior authorization processes preferred • Experience with CarePort Care Management preferred • Willingness 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 • Applicants for U.S.-based positions must be legally authorized to work in the United States

🏖️ Benefits

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

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