Nurse Clinical Review
Nurse Clinical Review
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Not Disclosed
Salary Not Disclosed
1 Vacancy
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 HealthHelps 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 companys 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
Additional Information :
Compensation Disclosure
The base salary range for this position is $65000 LVN/LPN $75000 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 candidates 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
Remote Work :
Yes
Employment Type :
Full-time
Employment Type
Remote
