Nurse Team Lead – Clinical Review

🔥 10 hours ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $74.9k - $85.3k / year

⏰ Full Time

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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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

• Serve as the clinical subject matter expert for assigned programs and modalities • Answer nurses’ criteria, guideline, and process questions • Perform prospective case reviews while maintaining Team Lead productivity and quality standards • Handle complex, escalated, and expedited cases and escalated inbound provider calls and requests • Interpret HealthHelp clinical guidelines, client medical policies, and regulatory requirements • Coordinate daily physician reviewer case flow and notifications • Monitor case inventory, queues, and turnaround times • Adjust the nurse assignment tool based on staffing, proficiency, request type, and volume • Use productivity, turnaround-time, and queue reports to identify backlogs, outliers, and trends • Recommend staffing or workflow changes to the Supervisor • Use AVAYA, ADP Workforce Now, and related systems to manage phone and staffing metrics • Audit nurse case work for determination appropriateness, documentation, and denial-related language • Support new nurses through orientation and ramp with QA audits and feedback • Conduct regular one-on-ones with Clinical Review Nurses • Recommend improvements to clinical review processes, criteria application, tools, and job aids • Provide secondary Nursing Management coverage when the Supervisor or Manager is unavailable • Communicate assignments, expectations, and changes to frontline staff • Resolve or escalate day-to-day issues and foster a respectful team environment • Lead or participate in team meetings • Collaborate with departments and client personnel to resolve concerns and obtain clarifications • Ensure compliance with benefit management, HIPAA, state and federal regulations, URAC, and NCQA standards • Refer complaints to the Compliance Officer and work with Quality to investigate and correct errors • Evaluate and report HIPAA breaches • Perform other related duties and projects as assigned

🎯 Requirements

• Graduate of an accredited school of nursing • Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory • Minimum of three (3) years of prospective utilization management experience making medical necessity determinations • Experience auditing or reviewing other reviewers’ case work, precepting or training new staff, or serving as a go-to clinical resource for a team • Sustained performance at or above productivity and quality standards in the current or most recent review role • Expert application of evidence-based criteria such as InterQual, MCG, or proprietary guidelines across more than one program or modality • Working knowledge of utilization management regulatory and accreditation requirements, including URAC, NCQA, CMS and state turnaround times, Medicare NCDs/LCDs, and denial notice requirements • Strong analytical skills and proficiency using Excel, including sorting, filtering, formulas, and pivot tables • Ability to manage inventory and multiple priorities in a fast-paced, changing environment • Clear, professional written and verbal communication, including giving constructive feedback • Proficiency in Microsoft Office: Outlook, Excel, Word, and PowerPoint; Visio is a plus • HIPAA-compliant remote location with reliable high-speed internet • Availability for a shift within 7:00 AM–7:00 PM CT, potentially including a late shift • After-hours on-call may be required • Ability to use the telephone, sit, enter data, and view a PC screen for up to 8 hours • Ability to prioritize in a multi-task environment

🏖️ 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