Nurse - Clinical Review

HealthHelp•Houston, TX

1d•Remote

About The Position

The Clinical Review Nurse makes prospective medical necessity determinations on prior authorization requests for HealthHelp specialty programs, including Diagnostic Imaging, Cardiology, Musculoskeletal, Physical Medicine, Sleep, Oncology, and Genetic Testing. Reviewers apply HealthHelp’s proprietary, evidence-based clinical guidelines, approve requests that meet criteria, and refer requests that do not meet criteria to Physician Reviewers. This is a full-time, fully remote, production-based role. Reviewers are expected to meet daily productivity and quality standards, measured by cases per hour and QA audits. New reviewers complete structured training on HealthHelp’s guidelines and systems, followed by a supported production ramp period. The training schedule for the first six weeks is Monday to Friday, 8:00 AM–4:30 PM CST. After training, the regular schedule is 10:30 AM–7:00 PM CST. The position is remote within the United States. The base salary is $65,000 annually for LVN/LPN candidates and $75,000 annually for RN candidates. The role may also be eligible for performance-based bonuses, incentive pay, or commissions. This is a dedicated role; other employment must be disclosed in line with HealthHelp policy.

Requirements

Graduate of an accredited RN or LPN/LVN nursing program.
Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.
At least two years of experience reviewing prior authorization or utilization review requests against clinical criteria, such as prior authorization, pre-service review, precertification, or utilization review.
Ability to work in a production environment with daily productivity and quality standards.
Accurate, efficient typing and clinical documentation skills.
Proficiency in Microsoft Office and ability to learn new healthcare software and work in several systems at once.
Reliable high-speed internet and a private, HIPAA-compliant home workspace.

Nice To Haves

Experience making prospective medical necessity determinations at a health plan, utilization management organization, specialty or radiology benefit manager, or workers’ compensation utilization review program.
Track record of meeting a measured daily case target and QA or accuracy standard.
Working knowledge of InterQual, MCG, ODG, or other evidence-based criteria sets.
Working knowledge of Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
Review experience in Diagnostic Imaging, Cardiology, Musculoskeletal, Oncology, Sleep, Genetic Testing, or another HealthHelp program area.
Multistate (compact) nursing license.
Experience working remotely.

Responsibilities

Perform prospective utilization review of prior authorization requests to determine whether they meet medical necessity criteria under HealthHelp clinical guidelines, client medical policies, and applicable state and federal requirements.
Identify clinical indications, criteria met or not met, and missing documentation; approve requests that meet criteria and refer other requests to Physician Reviewers with a clear, concise clinical summary.
Meet established productivity and quality standards and complete reviews within state, federal, and client turnaround timeframes.
Document each review accurately and completely according to HealthHelp’s documentation policy.
Contact ordering and rendering providers, office staff, and members to obtain additional clinical information and communicate determinations professionally.
Handle escalated and expedited cases requiring special handling.
Support Physician Reviewers and Medical Directors in keeping cases within review timeframes.
Identify and refer potential quality-of-care concerns to UM Leadership.
Participate in the HealthHelp Quality Management Program, including QA audits and calibration, and apply feedback to improve accuracy.
Keep current with guideline, policy, and regulatory updates and adhere to URAC, NCQA, HIPAA, and state and federal requirements.
Work in multiple computer systems simultaneously to manage cases and document reviews.
Collaborate with client personnel and internal teams to resolve concerns and contribute to a respectful, cooperative, and inclusive team environment.
Perform other related duties and projects as assigned to meet business needs.