Nurse, Concurrent Review

WNS Global Services•Houston, TX

7h•Remote

About The Position

The Nurse, Concurrent Review performs concurrent inpatient utilization reviews using InterQual criteria and applicable HealthHelp or client medical policies to assess medical necessity and level of care. Reviews include admissions, continued stays, and transitional care involving Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, and Long-Term Acute Care Hospitals, along with follow-up activities and documentation updates. The role collaborates with attending physicians, hospitalists, care teams, facility staff, and client personnel to obtain clinical information, communicate clinical rationale, support appropriate level-of-care decisions, and resolve customer concerns. The nurse handles escalated cases, refers cases to Physician Reviewers or Specialty Program Medical Directors when indicated, and assists reviewers and medical directors with meeting review timeframes. The position requires accurate confidential documentation and compliance with HIPAA, state and federal regulations, URAC and NCQA standards, and applicable payer-specific requirements. The nurse supports quality and compliance initiatives, identifies quality issues, and participates in the HealthHelp Quality Management Program as required. Work is 100% remote, with equipment provided. The scheduled shift is eight hours Monday through Friday within the stated daytime hours, with flexibility potentially needed for weekends or alternative daytime hours based on business needs and client obligations. The position requires 100% attendance during the first 90 days.

Requirements

Graduate of an accredited school of nursing; a BSN is preferred.
Current, active, unrestricted RN license in a U.S. state or territory, or USRN equivalent.
Two years of experience in an acute care setting.
Proficient technical skills in Microsoft Word, Excel, and PowerPoint.
Good organizational and time-management skills.
Excellent written and verbal communication skills.
Ability to use critical-thinking skills.
Ability to work efficiently and independently or as a team member.
Willingness to complete and maintain InterQual certification and ongoing competency requirements.
Ability to meet the position's attendance requirement of 100% attendance during the first 90 days.

Nice To Haves

Two years of inpatient clinical nursing, utilization management, or case management experience.
Experience with InterQual or similar evidence-based clinical decision support criteria.
Familiarity with inpatient level-of-care criteria, observation-versus-inpatient status determinations, and transitional care planning.
Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements.
Knowledge of insurance terminology.
Experience working with state and federal regulatory and compliance standards.

Responsibilities

Perform concurrent inpatient utilization reviews using InterQual criteria, including admission, continued stay, and transitional care reviews.
Complete related follow-up activities and update documentation.
Collaborate with attending physicians, hospitalists, care teams, and facility staff to obtain clinical information and discuss medical necessity determinations and level-of-care decisions.
Communicate clinical rationale during real-time concurrent review interactions.
Facilitate resolution of escalated cases that require special handling.
Refer cases to a Physician Reviewer or Specialty Program Medical Director according to guidelines.
Assist Physician Reviewers and Medical Directors as needed to meet review timeframes.
Maintain written documentation according to HealthHelp documentation policy.
Apply InterQual criteria, HealthHelp or client medical policies, and applicable state- and market-specific regulations, accreditation requirements, and payer guidelines.
Adhere to HIPAA and applicable state and federal regulations, and comply with URAC, NCQA, and other requisite standards.
Work with Nursing Management to ensure consistent implementation of policies, procedures, and regulatory requirements; keep current with regulatory changes.
Support Compliance Department initiatives and updates as a subject matter expert.
Collect and enter confidential information while maintaining confidentiality.
Perform clinical intake and review cases according to HealthHelp policies and procedures, including cases with expedited turnaround times.
Maintain availability for concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays.
Prioritize multiple tasks, work independently under pressure, and meet critical deadlines.
Identify and refer quality issues to UM Leadership.
Collaborate with client personnel to resolve customer concerns and provide quality service to providers, administrative staff, and others.
Support a work environment that fosters teamwork, respect, diversity, and cooperation.
Participate in the HealthHelp Quality Management Program as required.
Perform other related duties and projects as assigned.

Benefits

Medical insurance
Dental insurance
Vision insurance
Paid time off
Paid holidays
Sick leave
401(k) with company match or other retirement plan
Life and AD&D insurance
Employee Assistance Program
Potential eligibility for performance-based bonuses, incentive pay, or commissions