Nurse, Concurrent Review

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🤠 Texas – Remote

🤠 Texas – Remote

💵 $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

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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 concurrent inpatient utilization reviews using InterQual criteria to determine medical necessity • Conduct admission, continued-stay, and transitional-care reviews • Complete follow-up activities and documentation updates • Collaborate clinically with attending physicians, hospitalists, and care teams to obtain clinical information and support level-of-care decisions • Communicate clinical rationale during real-time concurrent review interactions • Facilitate resolution of escalated cases and refer cases to Physician Reviewers or Specialty Program Medical Directors • Assist Physician Reviewers and Medical Directors to ensure compliance with review timeframes • Maintain written documentation according to HealthHelp policy • Apply regulatory, accreditation, payer-specific, InterQual, and HealthHelp/client medical policies • Adhere to HIPAA, state, and federal regulations and URAC/NCQA standards • Support Compliance Department initiatives and updates as a subject matter expert • Collect and enter confidential information • Perform clinical intake and review expedited cases • Support concurrent review coverage, including non-standard hours, weekends, and holidays when required • Identify and refer quality issues to UM Leadership • Collaborate with client personnel to resolve customer concerns • Provide quality customer service to providers, administrative staff, and others • Participate in the HealthHelp Quality Management Program • Perform other related duties and projects as assigned

🎯 Requirements

• RN graduate from an accredited school of nursing (BSN preferred) • Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent) • Two (2) years of experience in an acute care setting, required • Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred • Experience with InterQual or similar evidence-based clinical decision support criteria, preferred • Willingness to complete and maintain InterQual certification and ongoing competency requirements • Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred • Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements • Knowledge of insurance terminology • Experience working with state and federal regulatory and compliance standards, preferred • Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required • 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 • Flexibility to work weekends or alternative daytime hours based on business needs • 100% attendance required for the first 90 days

🏖️ Benefits

• Medical, dental, and vision insurance • Paid time off (PTO), holidays, and sick leave • 401(k) with company match or other retirement plan • Life and AD&D Insurance • Employee Assistance Program • Performance-based bonuses, incentive pay, or commissions may be available • Equipment provided (mini desktop, dual monitors, mouse, keyboard, headset)

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