Nurse, Concurrent Review

    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
    Engages 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 HealthHelps 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 companys 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 

Qualifications :

    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

Additional Information :

The base salary for this position is $75000 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.

Location - Remote

WNS HealthHelp (A Capgemini Company) provides cutting-edge technology to streamline the review process including our proprietary HIPAA compliant portal and Physician App ensuring efficiency and ease of use for our specialists.

WNS HealthHelp (A Capgemini Company) is an Equal Opportunity Employer. At WNS HealthHelp we celebrate diversity and are committed to creating an inclusive environment that extends to our suppliers and vendors. All qualified Independent Contractors will receive consideration 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.

Remote Work :

Yes

Employment Type :

Full-time