Nurse, Concurrent Review

🔥 3 hours ago

🤠 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

📦 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 concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including: • Admission reviews • Continued stay reviews • Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital) • Related follow-up activities and documentation updates • Engage in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions • Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions • Facilitates resolution of escalated cases that may require special handling • Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines • Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes • Maintains written documentation according to HealthHelp’s documentation policy • Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations • Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs • Complies with URAC & NCQA standards or other requisite regulating bodies • 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 • Functions as subject matter expert to support Compliance Department initiatives and updates • Collects and enters confidential information ensuring the highest level of confidentiality in all areas • Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times • Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes • Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines • Appropriately identifies and refers quality issues to UM Leadership • Collaborates with client personnel to resolve customer concerns • 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 • Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy • Participates in the HealthHelp Quality Management Program, as required • Performs other related duties and projects as assigned to meet business needs

🎯 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

🏖️ 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