Authorization Management Clinical Reviewer

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.

What we’re looking for:

• 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, familiarity with CarePort Care Management preferred.
• Licensed RN, with the ability to obtain other clinical state licensures, as needed.
• Flexibility to work weekend and evening rotation in alignment with the following business hours: 7:00a – 7:00p (staggered shifts) central time on weekdays, 8:00a – 5:00p on Saturdays and Sundays.
• Join us in shaping the future of healthcare - apply today!

Key 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.
• Required Qualifications: 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.

Preferred Qualifications:

• 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.
• Job Expectations: 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.
• WellSky 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.
• Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky:
• Excellent medical with Rx, dental, and vision benefits
• Mental Health support through EAP
• Generous paid time off, plus 13 paid holidays
• 100% vested 401(K) retirement plans
• Educational assistance up to $2500 per year
• 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.
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