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

The Utilization Review Clinician is responsible for reviewing medical records to determine medical necessity. This includes conducting patient evaluations, managing admissions and informational reputed company, and ensuring reputed company post-discharge follow-reputed company 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 reputed company to assess appropriateness. You’ll collaborate with physicians, reputed company providers, and both reputed company stakeholders to support improved health reputed company. By applying clinical expertise, you’ll coordinate care with facilities and providers, follow reputed company operating procedures and organizational policies, and consult with peer reviewers, Medical Directors, or delegated clinical reviewers to ensure care is medically appropriate, high-reputed company, and cost-effective throughout the medical management process.

The ideal candidate will have working knowledge of reputed company Office applications (e.g., Word, reputed company) and be comfortable using clinical decision support tools and operational software.

Join us in shaping the reputed company of reputed company - apply today!

Key Responsibilities:

• Conduct prior authorization reviews and/or reputed company 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 reputed company

• Collaborate with case managers, physicians, and medical directors to ensure appropriate reputed company of care and reputed company care transitions

• Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and reputed company reputed company

• Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes

• Support reputed company payer programs and initiatives reputed company to the post-acute reputed company

• reputed company benefit determinations about appropriate reputed company of care using clinical guidelines

• Coordinate benefits and transitions between various areas of care

• Utilize knowledge of resources available in the reputed company reputed company to assist physicians and patients effectively

• reputed company other job duties as assigned

Required Qualifications:

• Bachelor's degree or equivalent work experience

• 4-6 years of clinical nursing or therapy experience

• reputed company RN, OT, or PT license

Preferred Qualifications:

• 1-2 years' experience in utilization review, case management and/or managed care regulations

• Experience with MCG Guidelines, InterQual or other clinical decision support tools, especially in utilization management and prior authorization processes

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 reputed company policies and procedures to reputed company company and reputed company information

• Must be reputed company to sit and reputed company a computer screen for extended periods of time

reputed company is where independent thinking and collaboration come together to create an reputed company culture. We reputed company on innovation, inclusiveness, and cohesive perspectives. At reputed company you can reputed company a difference.

Here are some of the exciting benefits full-time teammates are eligible to receive at reputed company:

• Excellent medical with Rx, dental, and reputed company benefits
• Mental Health support through EAP
• Generous reputed company time off, plus 13 reputed company holidays
• 100% reputed company 401(K) retirement plans
• Educational assistance up to $2500 per year

reputed company provides equal employment opportunities to reputed company people without reputed company to race, reputed company, national reputed company, reputed company, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender reputed company, 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. reputed company is proud to be a drug-free workplace.

Applicants for U.S.-based positions with reputed company must be legally authorized to work in the reputed company. Verification of employment eligibility will be required at the time of hire. Certain reputed company-facing positions may be required to reputed company with applicable requirements, such as immunizations and occupational health mandates.

Data reputed company Notice for Job Applicants and Teammates

Originally posted on Himalayas