Nurse - Clinical Review

WNS Global Services•Houston, TX

9h•Remote

About The Position

This role involves performing utilization reviews to determine if requests meet medical necessity criteria according to established medical policies and governing bodies. The position requires facilitating the resolution of escalated cases, conducting clinical reviews within specified timeframes, and collaborating with client personnel to address concerns. The nurse will also identify and refer quality issues, assist Physician Reviewers and Medical Directors, and maintain accurate documentation. Ensuring consistency in policy implementation, staying current with regulations, and adhering to HIPAA, state, and federal regulations are key responsibilities. The role also emphasizes providing quality customer service, fostering a team environment, and engaging in phone conversations with various healthcare professionals to facilitate the review process. Effective use of computer systems for case management and documentation is essential, along with promoting business focus and participating in quality management programs. Adherence to URAC & NCQA standards is required, along with the ability to prioritize, work independently under pressure, meet deadlines, and communicate clinical concepts effectively.

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 experience in utilization review, case management, or clinical quality improvement
Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint) and ability to adapt to new healthcare specific software and systems, required
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 working with state and federal regulatory and compliance standards, preferred

Responsibilities

Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body.
Facilitates resolution of escalated cases that may require special handling.
Performs clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes.
Collaborates with client personnel to resolve customer concerns.
Appropriately identifies and refers quality issues to UM Leadership.
Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.
Maintains written documentation according to HealthHelp’s documentation policy.
Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.
Keeps current with regulation changes as provided by Compliance Department and Nursing Management.
Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs.
Provides quality customer service through interaction with providers, administrative staff, and others.
Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others.
Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions.
Effectively utilizes various computer systems and software to manage cases and document reviews.
Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy.
Participates in the HealthHelp Quality Management Program, as required.
Adheres to both URAC & NCQA standards pertinent to their job description.
Ability to prioritize projects, work independently under pressure, and meet critical deadlines.
Capable of communicating clinical concepts to providers and staff based on guidelines.
Performs other related duties and projects as assigned to meet business needs.