Nurse – Clinical Review

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🕒 vor 9 Tagen

🇺🇸 Vereinigte Staaten – Remote

💵 $65.000 - $75.000 / Jahr

⏰ Vollzeit

🟢 Junior

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WNS

WebsiteLinkedInAlle Stellen

10.000+ Mitarbeiter

Gegründet 1996

⚖️ Rechtswesen

📦 Logistik

📣 Marketing

Legal • Logistics • Marketing

WNS ist ein globales Unternehmen für Business Process Management, das in 13 Ländern tätig ist, über 66 Lieferzentren verfügt und mehr als 62. 000 Mitarbeiter beschäftigt. Das Unternehmen setzt sich für Inklusivität und Vielfalt ein und fördert eine einzigartige Kultur der Co-Kreation und des kontinuierlichen Lernens. WNS bietet vielfältige Karrieremöglichkeiten in der Asien-Pazifik-Region, Europa, Afrika und Amerika und stolz auf einen transparenten und leistungsbasierten Rekrutierungsprozess. Als führendes Unternehmen in seinem Bereich konzentriert sich WNS darauf, zukünftige Führungskräfte und Entscheidungsträger zu fördern und legt dabei großen Wert auf soziale Verantwortung durch Initiativen wie die WNS Cares Foundation.

Beschreibung

• 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.

🎯 Anforderungen

• 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 one (1) year experience in utilization review, or utilization management • 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

🏖️ Vorteile

• Medical • Dental • Vision • 401K plan