Utilization Review Clinician - Appeals

The Appeal Review Clinician is responsible for handling appeals cases and relevant information. The scope of this job may include handling health plan and Medicare Quality Improvement Organization (QIO) appeals, including expedited appeals, reconsiderations and medical necessity reviews. This role ensures compliance with CMS regulations, organizational policies, and established clinical guidelines.

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Key Responsibilities:

• Review appeals submitted by members, providers, or authorized representatives related to denied authorizations, level of care determinations or coverage issues.
• Classify appeals accurately once received.
• Ensure each appeal meets regulatory, contractual and organizational filing requirements.
• Meet the required turnaround times to submit appeal packages to the QIO.
• Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes.
• Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth.
• 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 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.

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