Utilization Review Clinician - Appeals

WellSky

1d•Remote

About The Position

This role will require the successful candidate to work the shift of Wednesday to Saturday, 10 AM to 9PM Eastern. The Appeal Review Clinician is responsible for handling appeals cases and relevant information. The scope of this job may include handling health plan and Medicare Quality Improvement Organization (QIO) appeals, including expedited appeals, reconsiderations and medical necessity reviews. This role ensures compliance with CMS regulations, organizational policies, and established clinical guidelines. Join us in shaping the future of healthcare - apply today!

Requirements

Bachelor's degree or equivalent work experience.
4-6 years of clinical nursing or therapy experience.
Active RN, OT, or PT license.

Nice To Haves

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.

Responsibilities

Review appeals submitted by members, providers, or authorized representatives related to denied authorizations, level of care determinations or coverage issues.
Classify appeals accurately once received.
Ensure each appeal meets regulatory, contractual and organizational filing requirements.
Meet the required turnaround times to submit appeal packages to the QIO.
Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes.
Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth.
Perform other job duties as assigned.