Utilization Review Clinician – RN, PT, OT

🔥 2 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

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👻 Ghost score 10%

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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 medical records to determine medical necessity • Conduct patient evaluations, manage admissions and informational visits, and ensure timely post-discharge follow-ups with completed assessments to help prevent acute care readmissions • Review requests for post-acute services using established clinical guidelines and coverage criteria • Collaborate with physicians, healthcare providers, and internal and external stakeholders to support improved health outcomes • Coordinate care with facilities and providers throughout the medical management process • Consult with peer reviewers, Medical Directors, or delegated clinical reviewers to ensure care is medically appropriate, high-quality, and cost-effective • Conduct prior authorization reviews and/or continued stay reviews for post-acute care services • 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 • Utilize 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 • 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 (e.g., Word, 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 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 with WellSky must be legally authorized to work in the United States • Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates

🏖️ 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