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WellSky · 1 day ago

Authorization Management Clinical Reviewer

United States

Full-time

Remote

Mid, Senior Level

4+ years exp

WellSky is a company focused on creating an authentic culture through independent thinking and collaboration. The Authorization Management Clinical Reviewer will be responsible for reviewing acute and post-acute authorizations, ensuring medical necessity using InterQual guidelines, and collaborating with healthcare providers to support improved health outcomes.

Health CareSoftware

No H1B

Responsibilities

Review acute and post-acute authorizations for medical necessity using InterQual guidelines

Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care

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

Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively

Perform other job duties as assigned

Qualification

Active RN LicenseInterQual guidelinesUtilization management experienceAcute-care clinical backgroundCarePort Care ManagementCommunication skillsCritical thinkingProblem solvingOrganizational skills

Required

Bachelor's Degree or equivalent work experience

Active RN License

At least 4-6 years relevant work experience

2 years clinical acute nursing experience

1-2 years' of hospital-based utilization management experience

Preferred

Bachelor's Degree in Nursing

Denials and Appeals experience

Experience with managed care and CMS standards

UM/CM Knowledge of ICD / CPT / DRG's

Proficient in the use of window-based computer programs

Excellent verbal, written, and interpersonal communication skills

Critical thinking skills, creative problem solving, and proficient organization and planning skills

Experience with InterQual guidelines for acute-care and/or other clinical decision support tools, especially in utilization management and prior authorization processes

Experience with CarePort Care Management