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 We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach.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. If you need assistance in completing this application due to a disability, please contact a member of the Talent Acquisition Group to request an accommodation or an alternative application process by emailing

Job Description

•    Supervises a team of clinical staff with varying professional license and education levels

•    Conducts formal performance appraisals according to pre-determined performance metrics and measures of success and documents reviews and recommendations per HR policy at 90 days for newly hired staff, and annually for all direct reports 

•    Handles and reviews disciplinary actions directly with employees, i.e., verbal warnings, records of discussion, and formal disciplinary documentation. 

•    Enables team members to ensure consistent quality service to clients, providers and members

•    Continuously tracks and monitors program/client, team, and individual performance metrics and  provides feedback and coaching to ensure performance goals are achieved

•    Conducts formal Team and individual staff meetings to disseminate information

•    Serves as an additional training resource to improve effectiveness of the clinical assessment process in relation to new program updates and process changes.

•    Oversees and evaluates staff work assignments and makes appropriate adjustments to ensure case-specific turnaround times (TAT) related to client service level agreements and regulatory compliance requirements are met for their specified program(s) 

•    Partners with Workforce Planning to ensure appropriate resources are allocated to meet workload demand

•    Addresses escalated procedural and technical issues and coordinates with the appropriate departments to effectively resolve the issue(s)

•    Coordinates with Programs and Client Services to ensure appropriate business processes are being followed and enhancements are being developed and implemented

•    Identifies issues related to specific programs and makes suggestions for improving effectiveness and efficiency

•    Acts as first level liaison for escalated Client Service issues and actively determines best resolution

•    Develop, implement, and utilize a multifaceted rewards system that makes team members excited to show up to work every day and do their best

•    Use empowerment, trust and other strategies as appropriate to develop and motivate team members

•    Facilitate a healthy and motivating work environment and atmosphere

•    Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others

•    Utilizes knowledge of telephony, ACD, workforce, and related systems to manage daily phone metrics

•    Responsible for knowing the intricacies of all benefit management programs including applicable regulatory compliance, accreditation standards, and client/health plan service level requirements for each program, line of business, and geographic region 

•    Collaborates with human resources to ensure adherence to company policies

•    Refers all complaints to director of corporate compliance, works collaboratively with the compliance department to investigate complaints and correct errors

•    Assists with service restoration efforts during emergencies

•    Accurately answers questions regarding Plan benefits for members and providers

•    Promotes business focus which demonstrates an understanding to the company's vision, mission, and strategy

•    Utilizes knowledge of telephony, ACD, workforce, and related systems to manage daily phone metrics

•    Performs other related duties and projects as assigned

•    Adheres to all HIPAA, state and federal regulations pertaining to the clinical programs

•    Adheres to both URAC & NCQA standards pertinent to their job description

Qualifications

•    Current active unrestricted RN or LVN/LPN license in a state or territory of the United States required

•    Minimum 3 years' experience in UM/QM acute care or managed care setting required 

•    Minimum 2 years of progressively responsible supervisory experience in a managed care environment preferred

•    Excellent interpersonal, written and presentation skills, including the ability to handle interactions with facility personnel, providers, members and various internal departments in a professional manner 

•    Proficient leadership and facilitation skills

•    Ability to work in a fast-paced, evolving environment, on-call after hours work may be required 

•    Excellent organizational skills

•    Highly motivated, self-starter who works independently using all available resources, policies, and procedures to work effectively and meet deadlines in an atmosphere of multiple projects and shifting priorities

•    Demonstrated knowledge and experience in using critical thinking skills

•    Experience in team interactions and improvement methods/projects (e.g., coaching quality and productivity)

•    Knowledge of Microsoft Office and programs including Outlook, PowerPoint, Excel, Word and Visio

Additional Information

Compensation Disclosure

The base salary range for this position is $65,000 to $75,000 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.

•    Geographic location 

•    Overall professional experience

•    Directly relevant experience

•    Education and certifications

•    Industry knowledge and expertise

•    Skills and competencies

In addition to base pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed base salary range.

WNS complies with all applicable federal, state, and local pay transparency laws, including those in California, Colorado, New York, Washington, and Illinois.

Note: For complete compensation information, please refer to the job posting on our official careers page.

Benefits Overview

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.

We also provide reasonable accommodations to individuals with disabilities and for sincerely held religious beliefs in all aspects of employment, including the application process.

How to Apply

Please submit your application, including a resume and optional cover letter, through our careers page or email to