Utilization Review Clinician - RN - Remote

The Utilization Review Clinician is responsible for reviewing medical records to determine medical necessity.This role includes conducting patient evaluations, managing admissions and informational visits, and ensuring post-discharge visits occur within the required timeframe, with assessments completed to help prevent acute care readmissions.The Utilization Review Clinician also reviews requests for post-acute services in a timely manner, using established clinical guidelines and coverage limitations to assess appropriateness.They build relationships with physicians, healthcare providers, and internal / external clients to support improved health outcomes.Applying clinical expertise, they 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 possess working knowledge and aptitude of the Microsoft suite of applications (e.g., Office, Excel) as well as clinical decision support tools and operational software.We invite you to apply today and join us in shaping the future of healthcare!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 compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes.Support all payer programs and initiatives related to the post-acute space.Make benefit determinations about appropriate levels of care using clinical guidelines.Coordinate benefits and transitions between various areas of care.Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively.Perform other job duties as assigned.Required Qualifications :Bachelor's Degree or equivalent work experience4-6 years of clinical nursing or therapy experienceActive RN licensePreferred Qualifications :1-2 years' experience in utilization review, case management and / or managed care regulationsExperience with MCG Guidelines, InterQual or other clinical decision support tools, especially inutilization managementandprior authorizationprocessesLocated in the state of MichiganJob Expectations :Able to pass federal and state required background checks and drug screenWilling 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.Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky :Excellent medical, dental, and vision benefitsMental health benefits through TelaDocPrescription drug coverageGenerous paid time off, plus 13 paid holidaysPaid parental leave100% vested 401(K) retirement plansEducational assistance up to $2500 per year. Experience: 3 years required