Nurse, Concurrent Review

WNS Global Services•Houston, TX

21h•Remote

About The Position

This role performs concurrent inpatient utilization review using InterQual criteria to determine if requests meet medical necessity criteria. This includes admission reviews, continued stay reviews, and transitional care reviews for various facilities. The position involves clinical collaboration with physicians and care teams, communication of clinical rationale, and facilitation of escalated cases. The Nurse will also refer cases to Physician Reviewers or Medical Directors as needed and assist them to ensure compliance with review timeframes. Maintaining written documentation according to policy, understanding regulations, accreditation requirements, and payer-specific guidelines are crucial. The role requires adherence to HIPAA, state, and federal regulations, as well as URAC & NCQA standards. The Nurse will function as a subject matter expert, collect and enter confidential information, and perform clinical intake according to policies for expedited turnaround times. Availability to support concurrent review coverage, potentially including non-standard business hours, weekends, or holidays, is necessary. The ability to multitask, prioritize, work independently under pressure, and meet deadlines is essential. The role also involves identifying and referring quality issues, collaborating with client personnel, and providing quality customer service. Creating a teamwork-oriented environment, promoting business focus, and participating in the Quality Management Program are also key aspects of the position.

Requirements

RN graduate from an accredited school of nursing
Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent)
Two (2) years of experience in an acute care setting, required
Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required
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
Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements
Knowledge of insurance terminology
Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market

Nice To Haves

BSN preferred
Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred
Experience with InterQual or similar evidence-based clinical decision support criteria, preferred
Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred
Experience working with state and federal regulatory and compliance standards, preferred
Willingness to complete and maintain InterQual certification and ongoing competency requirements

Responsibilities

Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including admission reviews, continued stay reviews, and transitional care reviews.
Engages in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions.
Communicates clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions.
Facilitates resolution of escalated cases that may require special handling.
Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines.
Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.
Maintains written documentation according to HealthHelp’s documentation policy.
Applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations.
Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs.
Complies with URAC & NCQA standards or other requisite regulating bodies.
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.
Functions as subject matter expert to support Compliance Department initiatives and updates.
Collects and enters confidential information ensuring the highest level of confidentiality in all areas.
Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times.
Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes.
Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines.
Appropriately identifies and refers quality issues to UM Leadership.
Collaborates with client personnel to resolve customer concerns.
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.
Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy.
Participates in the HealthHelp Quality Management Program, as required.
Performs other related duties and projects as assigned to meet business needs.