Authorization Management Clinical Reviewer – Appeals and Denials

WellSky

. Review acute and post-acute authorization requests and medical records to evaluate medical necessity using established clinical guidelines .

Posted 11/5/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates strong acute-care clinical knowledge and expertise in medical necessity evaluations, denial management, and evidence-based appeals. Proficient in utilizing clinical guidelines and technology solutions to improve reimbursement outcomes and ensure compliance with healthcare standards.

Highest-signal resume keywords

Acute-Care Clinical BackgroundDenial Management ExperienceMedical Necessity Appeals DevelopmentUtilization Management KnowledgeInterQual Guidelines Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity EvaluationDenial ManagementEvidence-Based Guidelines ApplicationClinical Documentation ReviewAppeal Strategy DevelopmentICD KnowledgeCPT KnowledgeDRGs KnowledgeHospital Revenue Cycle WorkflowsUtilization Management Support Tools

Soft Skills

Critical ThinkingCreative Problem SolvingOrganizationPlanningInterpersonal Communication

Tools & Technologies

Microsoft OfficeCarePort Care ManagementWindow-Based Computer Programs

Certifications & Qualifications

Active RN LicenseBachelor's Degree

Industry Keywords

Acute Hospital SettingManaged CareCMS StandardsPeer-to-Peer ReviewsReconsiderationsFormal AppealsFederal ComplianceState ComplianceAccreditation StandardsHealthcare-System Resources

About the role

Key responsibilities & impact

Review acute and post-acute authorization requests and medical records to evaluate medical necessity using established clinical guidelines
Manage medical necessity denials from initial notification through final resolution
Apply acute-care clinical knowledge, payer requirements, and medical necessity criteria to determine appropriate resolution paths
Ensure timely follow-up and escalation of denials
Review clinical documentation, payer policies, and medical necessity criteria to develop comprehensive, evidence-based appeals within established deadlines
Identify denial trends, root causes, and process improvement opportunities to reduce preventable denials and improve reimbursement outcomes
Collaborate with physician advisors, utilization review nurses, hospital stakeholders, physicians, healthcare providers, and internal and external stakeholders
Determine appropriate appeal strategies, including peer-to-peer reviews, reconsiderations, and formal appeals
Review acute and post-acute authorizations 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
Ensure compliance with federal, state, and accreditation standards
Utilize healthcare-system resources to assist physicians and patients effectively
Perform other job duties as assigned

Requirements

What you’ll need

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
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
Experience with managed care and CMS standards preferred
Experience collaborating with physician advisors on peer-to-peer reviews, reconsiderations, and formal appeals preferred
UM/CM knowledge of ICD, CPT, DRGs, and hospital revenue cycle workflows preferred
Proficient in the use of window-based computer programs preferred
Excellent verbal, written, and interpersonal communication skills preferred
Critical thinking, creative problem solving, organization, and planning skills preferred
Experience with InterQual guidelines for acute-care and/or other clinical decision support tools, especially in utilization management and prior authorization processes preferred
Experience with CarePort Care Management preferred
Willingness 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
Applicants for U.S.-based positions must be legally authorized to work in the United States

Benefits

Comp & perks

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