Nurse - Clinical Review

•    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, or clinical quality improvement

•    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)

Compensation Disclosure

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.

•    Geographic location

•    Overall professional experience

•    Directly relevant experience

•    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.

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 We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach.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