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 handling.

• Execute clinical reviews in accordance with HealthHelp policies, procedures, and designated timeframes.

• Work collaboratively with client personnel to address customer concerns.

• Identify and escalate quality issues to UM Leadership.

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

• Maintain thorough written documentation in line with policy.

• Ensure adherence to policy, procedure, and regulatory standards.

• Stay updated on changes in regulations.

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

• Deliver exceptional customer service to providers, administrative staff, and other stakeholders.

• Engage in phone discussions with providers, members, internal staff, PCPs, and rendering providers.

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

• Participate in the HealthHelp Quality Management Program.

• Comply with URAC and NCQA standards.

• Prioritize tasks, work autonomously under pressure, and meet critical deadlines.

• Communicate clinical concepts to providers and staff based on established guidelines.

• Perform additional related duties and projects as assigned.

⛳️ Requirements

• RN, LPN/LVN graduate from an accredited nursing school.

• Current, active unrestricted RN, LPN/LVN license in the respective state or territory of the U.S.

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

• Strong technical skills in Microsoft Office (Word, Excel, and PowerPoint).

• Ability 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).

• Knowledge of insurance terminology.

• Strong organizational and time management skills.

• Excellent written and verbal communication abilities.

• Capacity to utilize critical thinking skills effectively.

• Highly motivated self-starter who can work efficiently and independently, as well as collaboratively as part of a team.

🏝️ Benefits

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

• Opportunity for remote work.

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

• Inclusive work environment.

• Specified training schedule and regular working hours.