Authorization Management Clinical Reviewer - Appeals and Denials

WellSky

22h•Remote

About The Position

The Authorization Management Clinical Reviewer – Appeals and Denials reviews acute and post-acute authorization requests and medical records to evaluate medical necessity using established clinical guidelines. The reviewer manages medical necessity denials from initial notification through final resolution, applying acute-care clinical knowledge, payer requirements, and medical necessity criteria to determine appropriate resolution paths, including peer-to-peer review, reconsideration, and formal appeal. The role collaborates with physicians, healthcare providers, and internal and external stakeholders to support appropriate levels of care and ensure reviews are accurate, consistent, timely, and compliant with applicable regulatory and organizational requirements. It also identifies denial trends and process-improvement opportunities, participates in educational and review-consistency activities, and uses healthcare-system resources to assist physicians and patients.

Requirements

Bachelor's degree or equivalent work experience.
Active RN license.
At least 4–6 years of relevant work experience.
At least 3 years of denial management experience in an acute hospital setting, including developing and submitting medical necessity appeals.
Two years of clinical acute nursing experience.
One to two years of hospital-based utilization management experience.
Strong acute-care clinical background and ability to apply evidence-based guidelines.
Proficiency with technology solutions, including Microsoft Office and utilization management support tools.
Ability to obtain other clinical state licenses as needed.
Willingness to work additional or irregular hours as needed.
Ability to sit and view a computer screen for extended periods.
Work in accordance with applicable security policies and procedures to safeguard company and client information.

Nice To Haves

Bachelor's degree in Nursing.
Denials and appeals experience.
Experience with managed care and CMS standards.
Experience collaborating with physician advisors on peer-to-peer reviews, reconsiderations, and formal appeals.
Utilization management or case management knowledge of ICD, CPT, DRGs, and hospital revenue-cycle workflows.
Proficiency using Windows-based computer programs.
Excellent verbal, written, and interpersonal communication skills.
Critical thinking, creative problem-solving, organization, and planning skills.
Experience with InterQual guidelines for acute care or other clinical decision-support tools, especially in utilization management and prior authorization.
Experience with CarePort Care Management.

Responsibilities

Manage medical necessity denials from initial notification through final resolution, ensuring timely follow-up and escalation.
Review clinical documentation, payer policies, and medical necessity criteria to develop comprehensive, evidence-based appeals within established deadlines.
Identify denial trends, root causes, and process-improvement opportunities to reduce preventable denials and improve reimbursement outcomes.
Collaborate with physician advisors, utilization review nurses, and hospital stakeholders to determine appeal strategies, including peer-to-peer reviews, reconsiderations, and formal appeals.
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.
Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes.
Use knowledge of healthcare-system resources to assist physicians and patients.
Perform other job duties as assigned.