Nurse - Clinical Review

WNS Global Services•Houston, TX

1d•$65,000 - $75,000•Remote

About The Position

The Nurse - Clinical Review performs utilization and clinical reviews to determine whether requests meet medical necessity criteria under client-approved medical policies and applicable regulations. The role handles escalated cases, supports Physician Reviewers and Medical Directors in meeting review timeframes, and collaborates with clients, providers, members, and internal staff to address concerns and facilitate appropriate care decisions. The position maintains documentation in accordance with HealthHelp policy, identifies and refers quality issues to UM Leadership, and supports consistent application of policies, procedures, and regulatory requirements. It follows HIPAA, state and federal regulations, URAC and NCQA standards, and participates in the HealthHelp Quality Management Program as required. The nurse uses computer systems and software to manage cases and document reviews, communicates clinical concepts, and contributes to a collaborative and respectful work environment. The position is remote within the United States. Training is Monday through Friday, 8:00 AM–4:30 PM CST for the first six weeks. After training, the regular schedule is 10:30 AM–7:00 PM CST. The annual base salary is $65,000 for LVN/LPN candidates or $75,000 for RN candidates. The role may also be eligible for performance-based bonuses, incentive pay, or commissions.

Requirements

Graduate of an accredited school of nursing as an RN, LPN, or LVN.
Current, active, unrestricted RN, LPN, or LVN license in a U.S. state or territory.
At least two years of experience in utilization review or utilization management.
Proficient with Microsoft Office, including Word, Excel, and PowerPoint, and able to adapt to new healthcare-specific software and systems.
Working knowledge of National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
Knowledge of insurance terminology.
Good organizational and time-management skills.
Excellent written and verbal communication skills.
Ability to use critical thinking skills.
Highly motivated self-starter able to work efficiently and independently or as a team member.

Nice To Haves

Experience working with state and federal regulatory and compliance standards.

Responsibilities

Perform utilization review of cases to determine whether requests meet medical necessity criteria under client-approved medical policies and applicable governing requirements.
Facilitate resolution of escalated cases that may require special handling.
Perform clinical reviews according to HealthHelp policies and procedures within applicable state, federal, or client-agreed timeframes.
Collaborate with client personnel to resolve customer concerns.
Identify quality issues and refer them to UM Leadership.
Assist Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.
Maintain written documentation according to HealthHelp’s documentation policy.
Collaborate with Nursing Management to ensure consistent implementation of policies, procedures, and regulatory requirements.
Keep current with regulatory changes communicated by the Compliance Department and Nursing Management.
Adhere to HIPAA and applicable state and federal regulations pertaining to clinical programs.
Provide quality customer service when interacting with providers, administrative staff, and others.
Support an environment that fosters teamwork, respect, diversity, and cooperation.
Engage in phone conversations with ordering providers, members, internal staff, PCPs, and rendering providers as needed to facilitate clinical review and appropriate care decisions.
Use computer systems and software to manage cases and document reviews.
Promote business focus and understanding of the company’s vision, mission, and strategy.
Participate in the HealthHelp Quality Management Program as required.
Adhere to applicable URAC and NCQA standards.
Prioritize projects, work independently under pressure, and meet critical deadlines.
Communicate clinical concepts to providers and staff based on guidelines.
Perform other related duties and projects as assigned to meet business needs.