Nurse – Clinical Review

Job not on LinkedIn

🔥 12 hours ago

🇷🇴 Romania – Remote

💵 $65k - $75k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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WNS

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1996

⚖️ Legal

📦 Logistics

📣 Marketing

Legal • Logistics • Marketing

WNS is a global business process management company that operates across 13 countries with over 66 delivery centers and employs more than 62,000 people. The organization is committed to inclusivity and diversity, fostering a unique culture of co-creation and continuous learning. WNS offers various career opportunities across the Asia Pacific, Europe, Africa, and the Americas, and prides itself on its transparent and merit-based recruitment process. As a leader in its field, WNS focuses on nurturing future leaders and decision-makers while maintaining a strong emphasis on social responsibility through initiatives like the WNS Cares Foundation.

📋 Description

• Perform utilization review of cases to determine whether requests meet medical necessity criteria • Facilitate resolution of escalated cases requiring special handling • Perform clinical reviews according to HealthHelp policies, procedures, and applicable timeframes • Collaborate with client personnel to resolve customer concerns • Identify and refer quality issues to UM Leadership • Assist Physician Reviewers and Medical Directors as necessary to meet review timeframes • Maintain written documentation according to HealthHelp policy • Ensure consistent implementation of policy, procedure, and regulatory requirements with Nursing Management • Keep current with regulation changes from Compliance and Nursing Management • Adhere to HIPAA, state, and federal regulations • Provide quality customer service to providers, administrative staff, and others • Support a respectful, diverse, cooperative, and team-oriented environment • Conduct phone conversations with providers, members, internal staff, PCPs, and rendering providers to facilitate clinical reviews and care decisions • Use computer systems and software to manage cases and document reviews • Participate in the HealthHelp Quality Management Program as required • Adhere to URAC and NCQA standards • Prioritize projects, work independently under pressure, and meet critical deadlines • Communicate clinical concepts to providers and staff based on guidelines • Perform other related duties and projects as assigned

🎯 Requirements

• 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) • Ability to adapt to new healthcare-specific software and systems • 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 • Ability to work the stated CST schedules

🏖️ Benefits

• Performance-based bonuses, incentive pay, or commissions may be available in addition to base pay • Remote work arrangement • Training schedule and structured onboarding during the first six weeks • Reasonable accommodations for individuals with disabilities and sincerely held religious beliefs