Authorization Management Clinical Reviewer

WellSky

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. WellSky is a technology company leading the movement for intelligent, coordinated care worldwide. Our next-level software, analytics, and services power better outcomes and lower costs for stakeholders across the health and community care continuum. In today’s value-based care environment, WellSky helps providers, payers, health systems, and community organizations solve tough challenges, improve collaboration for growth, harness the power of data analytics, and achieve better outcomes by further connecting clinical and social care.

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.
Licensed RN, with the ability to obtain other clinical state licensures, as needed.
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.
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.

Nice To Haves

Familiarity with CarePort Care Management 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.

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.