Nurse – Clinical Review

This is a fully remote position, open to applicants in Romania.

📋 Description

• Conduct utilization reviews of cases to assess whether requests align with medical necessity criteria.

• Manage the resolution of escalated cases that require special attention.

• Carry out clinical reviews in accordance with HealthHelp's policies, procedures, and designated timeframes.

• Partner with client personnel to address and resolve customer issues.

• Identify quality concerns and escalate them to UM Leadership.

• Provide assistance to Physician Reviewers and Medical Directors as needed to meet review deadlines.

• Maintain comprehensive written documentation as per HealthHelp policy.

• Ensure the consistent application of policies, procedures, and regulatory standards alongside Nursing Management.

• Stay updated on regulatory changes as communicated by Compliance and Nursing Management.

• Comply with HIPAA, as well as state and federal regulations.

• Deliver high-quality customer service to providers, administrative personnel, and other stakeholders.

• Foster a respectful, diverse, cooperative, and team-oriented workplace environment.

• Engage in telephone conversations with providers, members, internal staff, PCPs, and rendering providers to support clinical reviews and care decisions.

• Utilize computer systems and software to manage cases and document reviews effectively.

• Participate in the HealthHelp Quality Management Program as necessary.

• Comply with URAC and NCQA standards.

• Prioritize tasks, work independently in high-pressure situations, and meet essential deadlines.

• Convey clinical concepts to providers and staff in accordance with established guidelines.

• Execute other related duties and projects as assigned.

⛳️ Requirements

• RN or LPN/LVN graduate from an accredited nursing institution.

• Active, unrestricted RN, LPN/LVN license in the relevant U.S. state or territory.

• A minimum of two (2) years of experience in utilization review, case management, or clinical quality improvement.

• Proficient in Microsoft Office applications (Word, Excel, and PowerPoint).

• Capability to adapt to new healthcare-specific software and systems.

• Preferred experience with state and federal regulatory and compliance standards.

• Familiarity with National Coverage Determination (NCD) and Local Coverage Determination (LCD).

• Understanding of insurance terminology.

• Strong organizational and time management abilities.

• Exceptional written and verbal communication skills.

• Ability to apply critical thinking skills effectively.

• Highly motivated and self-driven, capable of working efficiently both independently and as part of a team.

• Willingness to work according to the specified CST schedules.

🏝️ Benefits

• Performance-based bonuses, incentive pay, or commissions may be available in addition to base salary.

• Flexible remote work arrangement.

• Organized training schedule and structured onboarding during the initial six weeks.

• Reasonable accommodations for individuals with disabilities and sincerely held religious beliefs.