Utilization Management Nurse Reviewer

  • WNS Global Services
  • Houston, TX, USA
  • Nov 21, 2021

Job Description

Company Description

HealthHelp - A WNS Company (), is the leader in the field of healthcare utilization & 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 We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach.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 has two locations in Houston, one a corporate office and the second a state-of-the art contact center. HealthHelp is also proud to have another such contact center in Albany, New York.

It is the policy of HealthHelp to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.

WNS Global Services Inc. (NYSE: WNS) is a global Business Process Management (BPM) leader. WNS offers business value to 400+global clients by combining operational excellence with deep domain expertise in key industry verticals, including Banking and Financial Services, Consulting and Professional Services, Healthcare, Insurance, Manufacturing, Retail and Consumer Packaged Goods, Shipping and Logistics, Telecommunications, Travel and Utilities. Globally, the group's over 44,000+ Professionals serve across 60 delivery centers in 16 countries worldwide.

Job Description

• Has a working knowledge of regulations and accreditation requirements by state and specific markets and applies appropriate LCD/NCD, HealthHelp or Client's medical policy guidelines
• Performs utilization review of cases to determine if the request meets criteria
• Facilitates resolution of escalated cases that may require special handling
• Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times
• Collects and enters confidential information ensuring the highest level of confidentiality in all areas
• Refers cases to a Physician Reviewer or Specialty Medical Director per guidelines
• Collaborates with client personnel to resolve customers concerns
• Appropriately identifies and refers quality issues to UM Leadership
• Assist Physician Reviewer Medical Directors as necessary to ensure timeframe compliance
• Maintains written documentation according to HealthHelp's documentation policy
• Ensures consistency in implementation of policy, procedure and regulatory requirements in collaboration with Nursing Management
• Keeps current with regulation changes as provided by Compliance Department and Nursing Management
• Functions as subject matter expert to support Compliance department initiatives and updates
• Adheres to all HIPAA, state and federal regulations pertaining to the clinical programs
• Provides quality customer service through interaction with providers, administrative staff and others.
• Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others
• Promotes business focus which demonstrates an understanding to the company's vision, mission, and strategy
• Participates in the HealthHelp Quality Management Program as required
• Adheres to both URAC & NCQA standards pertinent to their job description
• Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meets critical deadlines
• Capable of communicating clinical concepts to providers and staff based on guidelines
• Performs other related duties and projects as assigned to meet business needs


• 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 Three (3) years of experience in an acute care setting preferred
• Minimum of 2 years previous utilization review experience in a managed care setting required
• Familiar with State and Federal standards/requirements
• Working knowledge of NCDs, LCDs, MCG, and InterQual
• Knowledge of insurance terminology
• Experience working with state and federal regulatory and compliance standards, preferred
• Computer proficiency demonstrated by passing an "eSkills" exam
• Good organizational and time management skills required
• Excellent written and verbal communication skills
• Ability to utilize critical thinking skills
• Highly motivated, self-starter who can work efficiently and independently, or as a team member
• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint)

• Business office environment or HIPAA compliant remote location
• Ability to use telephone for up to 8 hours unassisted
• Ability to sit for up to 8 hours unassisted
• Ability to enter data for up to 8 hours unassisted
• Ability to view PC screen for up to 8 hours
• Ability to prioritize in a multi-task environment

Additional Information

All your information will be kept confidential according to EEO guidelines.