The Utilization Review Clinician is responsible for reviewing medical records to determine medical necessity. This includes conducting patient evaluations, managing admissions and informational visits, and ensuring timely post-discharge follow-ups with completed assessments to help prevent acute care readmissions.
In this role, you will also review requests for post-acute services promptly, using established clinical guidelines and coverage criteria to assess appropriateness. You’ll collaborate with physicians, healthcare providers, and both internal and external stakeholders to support improved health outcomes. By applying clinical expertise, you’ll coordinate care with facilities and providers, follow standard operating procedures and organizational policies, and consult with peer reviewers, Medical Directors, or delegated clinical reviewers to ensure care is medically appropriate, high-quality, and cost-effective throughout the medical management process.
The ideal candidate will have working knowledge of Microsoft Office applications (e.g., Word, Excel) and be comfortable using clinical decision support tools and operational software.
Join us in shaping the future of healthcare - apply today!
Key Responsibilities:
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
Required Qualifications:
Bachelor's degree or equivalent work experience
4-6 years of clinical nursing or therapy experience
Active RN, OT, or PT license
Preferred Qualifications:
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
Job Expectations:
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
WellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky you can make a difference.
WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law. WellSky is proud to be a drug-free workplace.
Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates.
Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky:
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