Utilization Review Clinician
UtilizationReviewClinician-RN,PT,orOT-Remote
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“Utilization Review Clinician - RN, PT, or OT - Remote at Utilization Review Clinician. Skills: Utilization Review, Clinical Review, Medical Necessity Determination, RN/PT/OT Licensure. Reviewing medical records to determine medical necessity. Conducting patient evaluations”
What You'll Achieve.
support improved health outcomes; ensure care is medically appropriate, high-quality, and cost-effective; maintain review consistency
Industry & Context.
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, 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
What They're Looking For.
Must Have
Active RN, OT, or PT license, 4-6 years of clinical nursing or therapy experience, Bachelor's degree or equivalent work experience
Nice to Have
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
What You'll Do.
Reviewing medical records to determine medical necessity
Conducting patient evaluations
Managing admissions and informational visits
Ensuring timely post-discharge follow-ups with completed assessments
Preventing acute care readmissions
Reviewing requests for post-acute services promptly
Using established clinical guidelines and coverage criteria to assess appropriateness
Coordinating care with facilities and providers
Following standard operating procedures and organizational policies
Consulting with peer reviewers
or delegated clinical reviewers
Conduct prior authorization reviews and/or continued stay reviews for post-acute care services
Approve services in compliance with health plan guidelines
contractual agreements
and medical necessity criteria
Make benefit determinations about appropriate levels of care using clinical guidelines
Coordinate benefits and transitions between various areas of care
Perform other job duties as assigned
How You'll Work.
Team & Collaboration
Collaborate with physicians, healthcare providers, and both internal and external stakeholders; Collaborate with case managers, physicians, and medical directors; Participate in team meetings
Communication Scope
enhance communication
Full Job Description
Job Description *****_ **This role will require the successful candidate to work the shift of Monday to Friday, 1pm to 10pm Central (2pm to 11pm Eastern).**_ 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 complian
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