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Clinical Nurse Specialist
4 weeks ago
The Utilization Review Nurse is responsible for performing prospective and retrospective reviews of post-acute care services to ensure that WellSky's population receives medically necessary services in the appropriate setting, with the appropriate provider, and at the appropriate level of care.
Key Responsibilities:- Perform initial prior authorization review of post-acute care services applying guideline criteria for approval and sending to Medical Directors if review is necessary for determining an adverse determination.
- Authorize post-acute care services in compliance with contractual agreements, health plan guidelines and medical necessity criteria.
- Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively.
- Successfully complete the Interrater Reliability Testing to ensure consistency of review and application of criteria.
- Make benefit determinations about appropriate levels of care using clinical guidelines.
- Coordinate benefits and transitions between various areas of care.
- Consult with the Medical Director as needed for complex cases.
- Apply clinical expertise when discussing case with internal and external Case Managers and Physicians.
- Follow all Standard Operating Procedures in end-to-end management of cases.
- Obtain clinical information to assess and expedite reviews as necessary.
- Participate in team meetings, education discussions and related activities.
- Maintain compliance with Federal, State and accreditation organizations.
- Identify opportunities for improved communication or processes.
- Works on a variety of special projects and assumes other duties as assigned.
- Active RN license.
- 5+ years of clinical nursing experience.
- RN Compact License highly preferred.
- Experience in utilization review, case management and/or managed care.
- MCG/ Interqual or other criteria-based applications.
- General understanding of managed care guidelines and impact on services.
- Graduate of an accredited school of nursing.
- Minimum of 1-2 years of utilization management experience, case management, managed care regulations; or any combination of education and experience, which would provide an equivalent background required.
- Able to pass federal and state required criminal / abuse background checks and drug screen.
- Computer skills including but not limited to MS Office, MS Excel, and Clinical / Operational Software.
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.
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.
