Nurse - Clinical Review

Healthhelp • Houston, TX

384d

About The Position

The Nurse - Clinical Review position at HealthHelp involves performing utilization reviews to assess medical necessity for healthcare requests. The role requires collaboration with various stakeholders to resolve escalated cases and ensure compliance with established medical policies and regulations. The nurse will also maintain documentation, provide quality customer service, and engage in teamwork to support the company's mission of improving healthcare delivery.

Requirements

• RN, LPN/LVN graduate from an accredited school of nursing.
• Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S.
• Minimum of two (2) years of clinical experience and/or in an administrative role.
• Experience in utilization review, case management, or clinical quality improvement preferred.
• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint).
• Ability to adapt to new healthcare specific software and systems required.
• Experience working with state and federal regulatory and compliance standards preferred.
• Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD).
• Knowledge of insurance terminology.
• Good organizational and time management skills.
• Excellent written and verbal communication skills.
• Ability to utilize critical thinking skills.
• Highly motivated, self-starter who can work efficiently and independently, or as a team member.

Nice To Haves

• Experience in utilization review, case management, or clinical quality improvement preferred.
• Experience working with state and federal regulatory and compliance standards preferred.

Responsibilities

• Perform utilization review of cases to determine if requests meet medical necessity criteria.
• Facilitate resolution of escalated cases requiring special handling.
• Conduct clinical reviews according to HealthHelp's policies and state and federal regulations.
• Collaborate with client personnel to resolve customer concerns.
• Identify and refer quality issues to UM Leadership.
• Assist Physician Reviewers and Medical Directors to ensure compliance with review timeframes.
• Maintain written documentation according to HealthHelp's documentation policy.
• Ensure consistency in policy implementation in collaboration with Nursing Management.
• Stay current with regulation changes provided by Compliance Department and Nursing Management.
• Adhere to HIPAA, state, and federal regulations pertaining to clinical programs.
• Provide quality customer service through interactions with providers and administrative staff.
• Engage in phone conversations with various stakeholders to facilitate the clinical review process.
• Utilize computer systems and software to manage cases and document reviews.
• Participate in the HealthHelp Quality Management Program as required.
• Adhere to URAC & NCQA standards pertinent to the job description.
• Prioritize projects and meet critical deadlines.
• Communicate clinical concepts to providers and staff based on guidelines.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Management of Companies and Enterprises
• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees