Nurse - Clinical Review
- 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