Nurse - Clinical Review

Job Description

Job Description

Company Description

HealthHelp - A WNS Company (www.HealthHelp.com), 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 We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach.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 talent@healthhelp.com

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

Additional Information

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.

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) :

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 talent@healthhelp.com.