Authorization Management Clinical Reviewer

🕒 July 10

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 53%

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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 authorizations for medical necessity using InterQual guidelines • Verify medical necessity before submission to the payer • Collaborate with physicians, healthcare providers, case managers, medical directors, and internal and external stakeholders • Support improved health outcomes and ensure care is medically appropriate, high-quality, and cost-effective • Participate in team meetings, educational activities, and interrater reliability testing • Ensure compliance with federal, state, and accreditation standards • Identify opportunities to enhance communication and processes • Utilize healthcare system resources to assist physicians and patients • 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 • Flexibility to work weekend and evening rotation • 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' 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 • Excellent verbal, written, and interpersonal communication skills preferred • Critical thinking skills, creative problem solving, and proficient organization and planning skills preferred • Experience with InterQual guidelines for acute-care and/or other clinical decision support tools preferred • Experience with CarePort Care Management preferred • 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 • 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