Nurse – Clinical Review

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

📋 Description

• Conduct prospective utilization reviews of prior authorization requests to assess whether the requests fulfill medical necessity criteria.

• Utilize HealthHelp clinical guidelines, client medical policies, and relevant state and federal regulations.

• Recognize clinical indications, determine criteria that are met or unmet, and identify any missing documentation.

• Approve requests that meet the criteria and direct non-qualifying requests to Physician Reviewers with clear clinical summaries.

• Achieve daily productivity, quality, and turnaround time benchmarks.

• Accurately document reviews in accordance with HealthHelp’s documentation policies.

• Engage with providers, office staff, and members to gather clinical information and convey determinations.

• Manage escalated and expedited cases effectively.

• Assist Physician Reviewers and Medical Directors in adhering to review timeframes.

• Identify and escalate potential quality-of-care issues to UM Leadership.

• Take part in quality management initiatives, including QA audits and calibration sessions.

• Stay updated on guidelines, policies, and regulatory changes.

• Navigate multiple computer systems to manage cases and document reviews.

• Collaborate with client personnel and internal teams to address concerns.

• Perform additional duties and projects as assigned.

⛳️ Requirements

• Graduate from an accredited RN or LPN/LVN nursing program.

• Hold a current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.

• Possess a minimum of two (2) years of experience in reviewing prior authorization or utilization review requests against clinical criteria.

• Ability to thrive in a production environment with daily productivity and quality expectations.

• Demonstrate accurate and efficient typing and clinical documentation capabilities.

• Proficient in Microsoft Office applications.

• Capability to learn new healthcare software and operate multiple systems concurrently.

• Maintain reliable high-speed internet and a private, HIPAA-compliant home workspace.

• Preferred: experience in making prospective medical necessity determinations within a health plan, utilization management organization, specialty or radiology benefit manager, or workers’ compensation utilization review program.

• Preferred: a proven history of meeting daily case targets and QA or accuracy standards.

• Preferred: familiarity with InterQual, MCG, ODG, or other evidence-based criteria sets.

• Preferred: understanding of Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).

• Preferred: review experience in Diagnostic Imaging, Cardiology, Musculoskeletal, Oncology, Sleep, Genetic Testing, or other HealthHelp program areas.

• Preferred: multistate (compact) nursing license.

• Preferred: experience working remotely.

🏝️ Benefits

• Comprehensive new employee orientation covering HealthHelp’s clinical guidelines and review platform.

• Production ramp-up period with regular QA audits and coaching sessions.

• Fully remote work opportunity.

• Performance-based bonuses, incentive pay, or commissions may be available.

• Reliable high-speed internet and a private, HIPAA-compliant home workspace are required for remote work.