Job Description

MAJOR RESPONSIBILITIES

• Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including:
• Admission reviews
• Continued stay reviews
• Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital)
• Related follow-up activities and documentation updates
• Engage in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions
• Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions
• Facilitates resolution of escalated cases that may require special handling
• Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines
• Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes
• Maintains written documentation according to HealthHelp’s documentation policy
• Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations
• Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs
• Complies with URAC & NCQA standards or other requisite regulating bodies
• 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
• Collects and enters confidential information ensuring the highest level of confidentiality in all areas
• Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times
• Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes
• Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines
• Appropriately identifies and refers quality issues to UM Leadership
• Collaborates with client personnel to resolve customer concerns
• 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 of the company’s vision, mission, and strategy
• Participates in the HealthHelp Quality Management Program, as required
• Performs other related duties and projects as assigned to meet business needs

SCHEDULE

7AM – 5PM PST/9AM – 7PM CST Monday- Friday while you should remain flexible based on business needs which could include weekends or alternative daytime hours.

Qualifications

QUALIFICATIONS

• RN graduate from an accredited school of nursing (BSN preferred)
• Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent)
• Two (2) years of experience in an acute care setting, required
• Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred
• Experience with InterQual or similar evidence-based clinical decision support criteria, preferred
• Willingness to complete and maintain InterQual certification and ongoing competency requirements
• Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred
• Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements
• Knowledge of insurance terminology
• Experience working with state and federal regulatory and compliance standards, preferred
• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required
• Good organizational and time management skills
• 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

Additional Information

Additional Information

The base salary for this position is $75,000 annually. This represents the base pay range that we reasonably expect to offer for this position.

Final compensation will be determined based on a variety of factors, including but not limited to the candidate’s experience, education, skillset, and location.

• Geographic location

• Overall professional experience

• Directly relevant experience

• Education and certifications

• Industry knowledge and expertise

• Skills and competencies

In addition to base pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed base salary range.

WNS complies with all applicable federal, state, and local pay transparency laws, including those in California, Colorado, New York, Washington, and Illinois.

Note: For complete compensation information, please refer to the job posting on our official careers page.

Benefits Overview

Our benefits package includes (but is not limited to):

- Medical, dental, and vision insurance

- Paid time off (PTO), holidays, and sick leave

- 401(k) with company match or other retirement plan

- Life and AD&D Insurance

- Employee Assistance Program

Equal Opportunity Employer Statement

WNS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other status protected under federal, state, or local law.

We also provide reasonable accommodations to individuals with disabilities and for sincerely held religious beliefs in all aspects of employment, including the application process.

Location - Remote

WNS HealthHelp (A Capgemini Company) provides cutting-edge technology to streamline the review process, including our proprietary HIPAA – compliant portal and Physician App, ensuring efficiency and ease of use for our specialists.

WNS HealthHelp (A Capgemini Company) **** is an Equal Opportunity Employer. At WNS HealthHelp, we celebrate diversity and are committed to creating an inclusive environment that extends to our suppliers and vendors. All qualified Independent Contractors will receive consideration without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other status protected under federal, state, or local law.