Nurse – Clinical Review

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

📋 Description

• Conducts utilization reviews of cases to assess whether requests align with medical necessity criteria as defined by the medical policies established with the Client and relevant governing bodies.

• Facilitates the resolution of escalated cases that may require specialized handling.

• Executes clinical reviews in accordance with HealthHelp's policies and procedures within the designated State and Federal or Client-mandated timelines.

• Partners with client personnel to address customer issues effectively.

• Appropriately identifies and escalates quality concerns to UM Leadership.

• Assists Physician Reviewers and Medical Directors as needed to maintain compliance with review timelines.

• Maintains documentation in accordance with HealthHelp’s documentation policy.

• Ensures consistent application of policies, procedures, and regulatory requirements in collaboration with Nursing Management.

• Stays informed of regulatory changes communicated by the Compliance Department and Nursing Management.

• Complies with all HIPAA, state, and federal regulations relevant to clinical programs.

• Provides excellent customer service through interactions with providers, administrative personnel, and others.

• Fosters an environment that promotes teamwork, respect, diversity, and collaboration.

• Engages in discussions with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions.

• Effectively utilizes various computer systems and software for case management and documentation of reviews.

• Promotes a business-oriented mindset that reflects an understanding of the company’s vision, mission, and strategy.

• Participates in the HealthHelp Quality Management Program as required.

• Adheres to URAC & NCQA standards relevant to the job description.

• Demonstrates the ability to prioritize projects, work independently under pressure, and meet critical deadlines.

• Capable of conveying clinical concepts to providers and staff based on established guidelines.

• Performs additional related duties and projects as assigned to fulfill business needs.

⛳️ Requirements

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

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

• A minimum of one (1) year of experience in utilization review or utilization management.

• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint) and the ability to adapt to new healthcare-specific software and systems is required.

• Experience with state and federal regulatory and compliance standards is preferred.

• Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD).

• Familiarity with insurance terminology.

• Strong organizational and time management abilities.

• Exceptional written and verbal communication skills.

• Ability to apply critical thinking skills effectively.

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

🏝️ Benefits

• Medical

• Dental

• Vision

• 401K plan