Authorization Management Clinical Reviewer

WellSky

3d•Onsite

About The Position

As an Authorization Management Clinical Reviewer, you’ll play a vital role in ensuring patients receive the right care at the right time. Your primary responsibility will be reviewing acute and post-acute authorizations before submission to the payer and verify medical necessity is met using InterQual guidelines. In this role, you’ll collaborate with physicians, healthcare providers, and both internal and external stakeholders to support improved health outcomes. By following InterQual guidelines, you will ensure care is medically appropriate, high-quality, and cost-effective throughout the medical management process.

Requirements

Strong acute-care clinical background with the ability to apply evidence-based guidelines.
Proficiency with technology solutions, including Microsoft Office and utilization management support tools, familiarity with CarePort Care Management preferred.
Licensed RN, with the ability to obtain other clinical state licensures, as needed.
Flexibility to work weekend and evening rotation in alignment with the following business hours: 7:00a – 7:00p (staggered shifts) central time on weekdays, 8:00a – 5:00p on Saturdays and Sundays.
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.

Nice To Haves

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.

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.