Nurse – Clinical Review

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🔥 4 minutes ago

🇺🇸 United States – Remote

💵 $65k - $75k / year

⏰ Full Time

🟢 Junior

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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

• 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.

🎯 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 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

🏖️ Benefits

• Medical • Dental • Vision • 401K plan