Clinical Review Nurse

4 days ago

Houston, Texas, United States WNS Global Services Full time
Job Title: Clinical Review Nurse

Job Summary:
HealthHelp, a WNS Global Services company, is seeking a skilled Clinical Review Nurse to join our team. As a Clinical Review Nurse, you will play a critical role in ensuring the quality and safety of patient care by reviewing medical necessity criteria and facilitating resolution of escalated cases.

Key Responsibilities:
• Perform 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.
• Facilitate resolution of escalated cases that may require special handling.
• Perform clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes.
• Collaborate with client personnel to resolve customer concerns.
• Appropriately identify and refer quality issues to UM Leadership.
• Assist Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.
• Maintain written documentation according to HealthHelp's documentation policy.
• Ensure consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.
• Keep current with regulation changes as provided by Compliance Department and Nursing Management.
• Adhere to all HIPAA, state, and federal regulations pertaining to the clinical programs.
• Provide quality customer service through interaction with providers, administrative staff, and others.
• Create, encourage, and support an environment that fosters teamwork, respect, diversity, and cooperation with others.
• Engage 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 utilize various computer systems and software to manage cases and document reviews.
• Promote business focus which demonstrates an understanding of the company's vision, mission, and strategy.
• Participate in the HealthHelp Quality Management Program, as required.
• Adhere 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.
• Perform other related duties and projects as assigned to meet business needs.

Requirements:
• 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 of clinical experience and/or in an administrative role
• Experience in utilization review, case management, or clinical quality improvement, preferred
• 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

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