Registered Nurse - Utilization Review

This job is responsible for reviewing medical records for medical necessity. The scope of this job includes providing skilled nursing care to patients, completing patient evaluations, admissions, and informational visits, and ensuring a post-discharge visit happens within specified timeframe following discharge with post-discharge assessments completed to minimize potential acute care readmission. This position is responsible for timely review of request for post-acute services and based on established clinical guidelines and/or coverage benefits limitations, determine appropriateness of requested services. The Utilization Review Nurse will comply with all standard operating procedures, and all departmental and organizational policies. They will develop relationships with physicians, healthcare service providers, internal and external customers to help improve health outcomes for enrollees. They will apply clinical knowledge to work with facilities and providers for care coordination. They will access and consult with peer clinical reviewers, Medical Directors, and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost-effective care throughout the medical management process. We invite you to apply today and join us in shaping the future of healthcare! Key Responsibilities: Conduct prior authorization 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 experience. Preferred Qualifications: 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. 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. #LI-PG1 #LI-Onsite 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 WellSky is a technology company leading the movement for intelligent, coordinated care worldwid