Nurse – Clinical Review

🔥 3 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $65k - $75k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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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 prospective utilization review of prior authorization requests to determine whether requests meet medical necessity criteria • Apply HealthHelp clinical guidelines, client medical policies, and applicable state and federal requirements • Identify clinical indications, criteria met or not met, and missing documentation • Approve requests meeting criteria and refer non-qualifying requests to Physician Reviewers with concise clinical summaries • Meet daily productivity, quality, and turnaround-time standards • Document reviews accurately according to HealthHelp’s documentation policy • Contact providers, office staff, and members to obtain clinical information and communicate determinations • Handle escalated and expedited cases • Support Physician Reviewers and Medical Directors in meeting review timeframes • Identify and refer potential quality-of-care concerns to UM Leadership • Participate in quality management activities, including QA audits and calibration • Keep current with guideline, policy, and regulatory updates • Work across multiple computer systems to manage cases and document reviews • Collaborate with client personnel and internal teams to resolve concerns • Perform related duties and projects as assigned

🎯 Requirements

• Graduate of an accredited RN or LPN/LVN nursing program • Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory • Minimum of two (2) years of experience reviewing prior authorization or utilization review requests against clinical criteria • Ability to work in a production environment with daily productivity and quality standards • Accurate, efficient typing and clinical documentation skills • Proficiency in Microsoft Office • Ability to learn new healthcare software and work in several systems at once • Reliable high-speed internet and a private, HIPAA-compliant home workspace • Preferred: experience making prospective medical necessity determinations at a health plan, utilization management organization, specialty or radiology benefit manager, or workers’ compensation utilization review program • Preferred: track record of meeting a measured daily case target and QA or accuracy standard • Preferred: working knowledge of InterQual, MCG, ODG, or other evidence-based criteria sets • Preferred: working knowledge of Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) • Preferred: review experience in Diagnostic Imaging, Cardiology, Musculoskeletal, Oncology, Sleep, Genetic Testing, or another HealthHelp program area • Preferred: multistate (compact) nursing license • Preferred: experience working remotely

🏖️ Benefits

• Structured new employee orientation on HealthHelp’s clinical guidelines and review platform • Production ramp period with regular QA audits and coaching • Fully remote work • Performance-based bonuses, incentive pay, or commissions may be available • Reliable high-speed internet and private HIPAA-compliant home workspace required for remote work