Utilization Review Clinician, RN, PT or OT

🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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

• Conduct prior authorization reviews and/or continued stay reviews for post-acute care services using clinical guidelines and escalate cases to medical directors as needed • Approve services in compliance with health plan guidelines, contractual agreements, and medical necessity criteria • Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care and seamless care transitions • Participate in team meetings, educational activities, and interrater reliability testing • Ensure compliance with federal, state, and accreditation standards and identify opportunities to enhance communication or processes • Support payer programs and initiatives related to the post-acute space • Make benefit determinations about appropriate levels of care using clinical guidelines • Coordinate benefits and transitions between various areas of care • Use healthcare-system resources to assist physicians and patients • Perform other job duties as assigned

🎯 Requirements

• Bachelor's degree or equivalent work experience • 4-6 years of clinical nursing or therapy experience • Active RN, OT, or PT license • Preferred: 1-2 years' experience in utilization review, case management and/or managed care regulations • Experience with MCG Guidelines, InterQual, or other clinical decision support tools, especially in utilization management and prior authorization processes • Working knowledge of Microsoft Office applications, including Word and Excel • Comfortable using clinical decision support tools and operational software • Willing to travel up to 30% based on business needs • Willing to work additional or irregular hours as needed • Must comply with applicable security policies and procedures • Able to sit and view a computer screen for extended periods • 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, plus 13 paid holidays • 100% vested 401(K) retirement plans • Educational assistance up to $2500 per year