Nurse, Concurrent Review

WNS Global Services•Houston, TX

2h•Remote

About The Position

WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. This role performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria. The position involves engaging in clinical collaboration with physicians and care teams, communicating clinical rationale, and facilitating the resolution of escalated cases. The Nurse will also maintain documentation, stay current with regulations, and ensure confidentiality. This role requires a strong understanding of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements. The position is remote and involves working with cutting-edge technology to streamline the review process.

Requirements

RN graduate from an accredited school of nursing (BSN preferred)
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
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), 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

Nice To Haves

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
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, 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, and transitional care reviews.
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.