[Hiring] Authorization Management Clinical Reviewer @WellSky

Role Description

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.

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.

Qualifications

• 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.

Requirements

• 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.

Benefits

• 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.