Authorization Management Clinical Reviewer - Appeals and Denials

Authorization Management Clinical Reviewer – Appeals and Denials

This job is responsible for reviewing acute and post-acute authorization requests and medical records to evaluate medical necessity using established clinical guidelines.

As a Denials and Appeals Clinical Reviewer, you will manage medical necessity denials from initial notification through final resolution. You will apply acute-care clinical knowledge, payer requirements, and medical necessity criteria to determine whether a denial should proceed to peer-to-peer review, reconsideration, formal appeal, or another appropriate resolution path.

The Clinical Reviewer collaborates with physicians, healthcare providers, and internal and external stakeholders to support appropriate levels of care and ensure medical necessity reviews are completed accurately, consistently, and in accordance with applicable regulatory and organizational requirements.

What we’re looking for:

• Strong acute-care clinical background with the ability to apply evidence-based guidelines.
• Proficiency with technology solutions, including Microsoft Office and utilization management support tools, familiarity with CarePort Care Management preferred.

• Licensed RN, with the ability to obtain other clinical state licensures, as needed.

 Join us in shaping the future of healthcare - apply today!

Key Responsibilities:

• Manage medical necessity denials from initial notification through final resolution, ensuring timely follow-up and escalation.
• Review clinical documentation, payer policies, and medical necessity criteria to develop comprehensive, evidence-based appeals within established deadlines.
• Identify denial trends, root causes, and opportunities for process improvement to reduce preventable denials and improve reimbursement outcomes.
• Collaborate with physician advisors, utilization review nurses, and hospital stakeholders to determine appropriate appeal strategies, including peer-to-peer reviews, reconsiderations, and formal appeals.
• Review acute and post-acute authorizations for medical necessity using InterQual guidelines.

• Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care.
• 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.
• 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.
• Active RN License.
• At least 4-6 years relevant work experience.
• At least 3 years of denial management experience in an acute hospital setting, including development and submission of medical necessity appeals.

• 2 years clinical acute nursing experience.
• 1-2 years' of hospital-based utilization management experience.

Preferred Qualifications:

• Bachelor's Degree in Nursing
• Denials and Appeals experience.
• Experience with managed care and CMS standards.
• Experience collaborating with physician advisors on peer-to-peer reviews, reconsiderations, and formal appeals.
• UM/CM Knowledge of ICD / CPT / DRG’s, and hospital revenue cycle workflows.
• Proficient in the use of window-based computer programs
• Excellent verbal, written, and interpersonal communication skills.
• Critical thinking skills, creative problem solving, and proficient organization and planning skills 
• Experience with InterQual guidelines for acute-care and/or other clinical decision support tools, especially in utilization management and prior authorization processes.
• Experience with CarePort Care Management.

 Job Expectations:

• 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.

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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.

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

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

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.

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