Utilization Review Clinician, RN, PT, OT

🔥 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 Insurance

☁️ SaaS

🤖 Artificial Intelligence

💰 Private Equity Round on 2020-07

Healthcare Insurance • SaaS • Artificial Intelligence

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 by applying clinical guidelines and escalating 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 to maintain review consistency and professional growth • Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes • Support all 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 knowledge of resources available in the healthcare system to assist physicians and patients effectively • 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 (preferred) • Experience with MCG Guidelines, InterQual or other clinical decision support tools, especially in utilization management and prior authorization processes (preferred)

🏖️ 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