Nurse, Concurrent Review
About The Position
WNS Healthhelp, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries, including Banking and Financial Services, Healthcare, Insurance, Shipping and Logistics, and Travel and Hospitality. We bring together deep domain excellence - WNS’ core differentiator - with AI-powered platforms and analytics to help businesses innovate, scale, adapt and build resilience in a world defined by disruption. Our purpose is clear: to enable lasting business value by designing intelligent, human-led solutions that deliver sustainable outcomes and a differentiated impact. With three global headquarters across four continents, operations in 13 countries, 65 delivery centers and more than 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact. Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including: Admission reviews, Continued stay reviews, Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital), Related follow-up activities and documentation updates. Engage 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. Capable of communicating 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. Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; 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.
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
- Two (2) years of inpatient clinical nursing, utilization management, concurrent experience
- Willingness to complete and maintain InterQual certification and ongoing competency requirements
- 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
- Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint)
- 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
- BSN preferred
- Experience with InterQual or similar evidence-based clinical decision support criteria, preferred
- Experience working with state and federal regulatory and compliance standards, preferred
Responsibilities
- Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including: Admission reviews, Continued stay reviews, Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital), Related follow-up activities and documentation updates
- Engage 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
- Capable of communicating 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
- Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; 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
Benefits
- Health, Dental, Vision, 401K, PTO
- Medical, dental, and vision insurance
- Paid time off (PTO), holidays, and sick leave
- 401(k) with company match or other retirement plan
- Life and AD&D Insurance
- Employee Assistance Program
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees
