WellSky · 15 hours ago
Utilization Review Clinician
United States
Full-time
Remote
Mid Level
4+ years expWellSky is a company focused on innovation and collaboration in the healthcare sector. The Utilization Review Clinician is responsible for reviewing medical records to determine medical necessity and coordinating care with various stakeholders to improve health outcomes.
Health CareSoftware
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
Qualification
Required
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
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
Company
WellSky
WellSky delivers software and services to transform an ever-growing range of care services worldwide.
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
unknownKey Investors
Leonard Green & Partners
2020-07-20Private Equity
Leadership Team
Joel Dolisy
CTO
Darren Yonkin
Vice President Of Product Management
Recent News
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