Utilization Review Clinician (RN, OT, or PT) - Remote

WellSky is one of America’s largest and most innovative healthcare technology companies leading the movement for intelligent, coordinated care. Our proven software, analytics, and services power better outcomes and lower costs for stakeholders across the health and community care continuum. In today’s value-based care environment, WellSky helps providers, payers, health systems, and community organizations scale processes, improve collaboration for growth, harness the power of data analytics, and achieve better outcomes by further connecting clinical and social care. WellSky serves more than 20,000 client sites — including the largest hospital systems, blood banks, cell therapy labs, home health and hospice franchises, post-acute providers, government agencies, and human services organizations. Informed by more than 40 years of providing software and expertise, WellSky anticipates clients’ needs and innovates relentlessly to build healthy, thriving communities. For more information, visit wellsky.com.

The Utilization Review Clinician is responsible for reviewing medical records to determine medical necessity. This includes conducting patient evaluations, managing admissions and informational visits, and ensuring timely post-discharge follow-ups with completed assessments to help prevent acute care readmissions. In this role, you will also review requests for post-acute services promptly, using established clinical guidelines and coverage criteria to assess appropriateness. You’ll collaborate with physicians, healthcare providers, and both internal and external stakeholders to support improved health outcomes. By applying clinical expertise, you’ll 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 have working knowledge of Microsoft Office applications (e.g., Word, Excel) and be comfortable using clinical decision support tools and operational software.

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