Nurse - Clinical Review

Company Description HealthHelp - A WNS Company ( is the leader in the field of healthcare utilization and care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that better inform physicians, and ensures quality and safety for the patients needing treatment. HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth. Our specialty benefits management services are broad and include, Cardiology, Oncology, Radiology, Radiation Therapy, Sleep Care, and Musculoskeletal Care. HealthHelp is headquartered in Houston, Texas. HealthHelp provides equal opportunities to all employees and applicants without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty or status as a covered veteran in accordance with applicable federal, state, and local laws. Job 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. Qualifications 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 two (2) years experience in utilization review, case management, 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 Compensation and Benefits The base salary range for this position is $65,000 (LVN/LPN), $75,000 (RN) annually. This represents the base pay range that we reasonably expect to offer for this position. Final compensation will be determined based on a variety of factors, including but not limited to the candidate’s experience, education, skillset, and location. Our benefits package includes (but is not limited to): 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 Equal Opportunity Employer Statement WNS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other status protected under federal, state, or local law. #J-18808-Ljbffr