Utilization Review Nurse - 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 experience
• 4-6 years of clinical nursing or therapy experience
• Active RN license

Preferred Qualifications:

• 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
• Located in the state of Michigan

Company DescriptionWellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky you can make a difference. WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law. WellSky is proud to be a drug-free workplace. 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. Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky: Excellent medical, dental, and vision benefits Mental health benefits through TelaDoc Prescription drug coverage Generous paid time off, plus 13 paid holidays Paid parental leave 100% vested 401(K) retirement plans Educational assistance up to $2500 per year Apply tot his job Apply To this Job