Nurse - Clinical Review

Job description

• Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body. • Facilitates resolution of escalated cases that may require special handling. • Performs clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes. • Collaborates with client personnel to resolve customer concerns. • Appropriately identifies and refers quality issues to UM Leadership. • Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes. • Maintains written documentation according to HealthHelp’s documentation policy. • 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. • Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs. • 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. • Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions. • Effectively utilizes various computer systems and software to manage cases and document reviews. • Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy. • Participates in the HealthHelp Quality Management Program, as required. • Adheres to both URAC & NCQA standards pertinent to their job description. • Ability to prioritize projects, work independently under pressure, and meet critical deadlines. • Capable of communicating clinical concepts to providers and staff based on guidelines. • Performs other related duties and projects as assigned to meet business needs. • RN, LPN/LVN graduate from an accredited school of nursing • Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S. • Minimum of two (2) years experience in utilization review, case management, or clinical quality improvement • Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint) and ability to adapt to new healthcare specific software and systems, required • Experience working with state and federal regulatory and compliance standards, preferred • Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD) • Knowledge of insurance terminology • 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 Training Schedule (First 6 Weeks): Monday to Friday, 8:00 AM – 4:30 PM (CST) Regular Schedule After Training: 10:30am CST - 7:00pm CST Location: Remote Compensation Disclosure The base salary for this position is $65,000 [LVN/LPN], $75,000 [RN] annually. This represents the base pay range that we reasonably expect to offer for this position. Final compensation will be determined based on a variety of factors, including but not limited to the candidate’s experience, education, skillset, and location. • Geographic location • Overall professional experience • Directly relevant experience • Education and certifications • Industry knowledge and expertise • Skills and competencies In addition to base pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed base salary range. WNS complies with all applicable federal, state, and local pay transparency laws, including those in California, Colorado, New York, Washington, and Illinois. Equal Opportunity Employer Statement WNS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other status protected under federal, state, or local law. We also provide reasonable accommodations to individuals with disabilities and for sincerely held religious beliefs in all aspects of employment, including the application process. How to Apply Please submit your application, including a resume and optional cover letter, through our careers page or email to . WNS, 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.