Utilization Review Clinician – Appeals

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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

• Handle health plan and Medicare Quality Improvement Organization (QIO) appeals, including expedited appeals, reconsiderations, and medical necessity reviews • Review appeals submitted by members, providers, or authorized representatives concerning denied authorizations, level of care determinations, or coverage issues • Classify appeals accurately upon receipt • Ensure appeals meet regulatory, contractual, and organizational filing requirements • Meet required turnaround times for submitting appeal packages to the QIO • Ensure compliance with federal, state, and accreditation standards • Identify opportunities to improve communication and processes • Participate in team meetings, educational activities, and interrater reliability testing • Perform other assigned duties

🎯 Requirements

• Bachelor's degree or equivalent work experience • 4-6 years of clinical nursing or therapy experience • Active RN, OT, or PT license • Willingness to work Monday to Friday, noon to 9pm Eastern, or Wednesday through Saturday, 10am to 9pm Eastern • Willingness to work additional or irregular hours as needed • Compliance with applicable security policies and procedures • Ability to sit and view a computer screen for extended periods • For U.S.-based positions, legal authorization to work in the United States • Preferred: 1-2 years' experience in utilization review, case management, and/or managed care regulations • Preferred: experience with MCG Guidelines, InterQual, or other clinical decision support tools, especially utilization management and prior authorization processes

🏖️ 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