Nurse – Clinical Review

Job Description

The Clinical Review Nurse makes prospective medical necessity determinations on prior authorization requests for HealthHelp’s specialty programs, including Diagnostic Imaging, Cardiology, Musculoskeletal, Physical Medicine, Sleep, Oncology, and Genetic Testing. Reviewers apply HealthHelp’s proprietary, evidence-based clinical guidelines, approve requests that meet criteria, and refer those that do not to Physician Reviewers.

This is a full-time, fully remote, production-based role. Reviewers work to daily productivity (cases per hour) and quality (QA audit) standards. New reviewers complete structured training on HealthHelp’s guidelines and systems, then move into production with a supported ramp period.

MAJOR RESPONSIBILITIES

• Performs prospective utilization review of prior authorization requests to determine whether each request meets medical necessity criteria under HealthHelp’s clinical guidelines, client medical policies, and applicable state and federal requirements.
• Identifies the clinical indication, the criteria met or not met, and any missing documentation; approves requests that meet criteria and refers those that do not to Physician Reviewers with a clear, concise clinical summary.
• Meets established productivity (cases per hour) and quality (QA audit) standards, and completes reviews within state, federal, and client turnaround timeframes.
• Documents each review accurately and completely according to HealthHelp’s documentation policy.
• Contacts ordering and rendering providers, office staff, and members to obtain additional clinical information and communicate determinations professionally.
• Handles escalated and expedited cases that require special handling.

• Supports Physician Reviewers and Medical Directors to keep cases moving within review timeframes.
• Identifies and refers potential quality-of-care concerns to UM Leadership.
• Participates in the HealthHelp Quality Management Program, including QA audits and calibration, and applies feedback to improve accuracy.
• Keeps current with guideline, policy, and regulatory updates from the Compliance Department and Nursing Management, and adheres to URAC, NCQA, HIPAA, and state and federal requirements.
• Works in multiple computer systems at the same time to manage cases and document reviews.
• Collaborates with client personnel and internal teams to resolve concerns, and contributes to a team environment of respect, cooperation, and inclusion.
• Performs other related duties and projects as assigned to meet business needs.

Qualifications

Required

• Graduate of an accredited RN or LPN/LVN nursing program.
• Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.
• Minimum of two (2) years of experience reviewing prior authorization or utilization review requests against clinical criteria (e.g., prior authorization, pre-service review, precertification, or utilization review).
• Ability to work in a production environment with daily productivity and quality standards.
• Accurate, efficient typing and clinical documentation skills.
• Proficiency in Microsoft Office and the ability to learn new healthcare software and work in several systems at once.
• Reliable high-speed internet and a private, HIPAA-compliant home workspace.

Preferred

• Experience making prospective medical necessity determinations at a health plan, utilization management organization, specialty or radiology benefit manager, or workers’ compensation utilization review program.
• Track record of meeting a measured daily case target and QA or accuracy standard.
• Working knowledge of InterQual, MCG, ODG, or other evidence-based criteria sets.
• Working knowledge of Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
• Review experience in Diagnostic Imaging, Cardiology, Musculoskeletal, Oncology, Sleep, Genetic Testing, or another HealthHelp program area.
• Multistate (compact) nursing license.
• Experience working remotely.

WHAT TO EXPECT

• Full-time, fully remote position. This is a dedicated role; other employment must be disclosed in line with HealthHelp policy.
• Structured new employee orientation on HealthHelp’s clinical guidelines and review platform, followed by a production ramp period with regular QA audits and coaching.
• Productivity is measured in cases per hour; quality is measured through regular QA audits.

Additional Information

Training Schedule (First 6 Weeks): Monday to Friday, 8:00 AM – 4:30 PM (CST)

Regular Schedule After Training: 10:30amCST - 7:00pm CST

Location: Remote (United States)

Compensation Disclosure

The base salary 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.

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.

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