Utilization Review Clinician - Remote

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.

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Key Responsibilities:

• 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

Required Qualifications:

• Bachelor's degree or equivalent work experience

• 4-6 years of clinical nursing or therapy experience

• Active 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 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