[Hiring] Clinical Review Nurse @WNS Global Services

Role Description

The Clinical Review Nurse makes prospective medical necessity determinations on prior authorization requests for HealthHelp’s specialty programs, including:

• Diagnostic Imaging
• Cardiology
• Musculoskeletal
• Physical Medicine
• Sleep
• Oncology
• Genetic Testing

Reviewers apply HealthHelp’s proprietary, evidence-based clinical guidelines, approve requests that meet criteria, and refer those that do not to Physician Reviewers.

This is a full-time, fully remote, production-based role. Reviewers work to daily productivity (cases per hour) and quality (QA audit) standards. New reviewers complete structured training on HealthHelp’s guidelines and systems, then move into production with a supported ramp period.

Qualifications

• Graduate of an accredited RN or LPN/LVN nursing program.
• Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.
• Minimum of two (2) years of experience reviewing prior authorization or utilization review requests against clinical criteria.
• Ability to work in a production environment with daily productivity and quality standards.
• Accurate, efficient typing and clinical documentation skills.
• Proficiency in Microsoft Office and the ability to learn new healthcare software and work in several systems at once.
• Reliable high-speed internet and a private, HIPAA-compliant home workspace.

Requirements

• Experience making prospective medical necessity determinations at a health plan, utilization management organization, specialty or radiology benefit manager, or workers’ compensation utilization review program.
• Track record of meeting a measured daily case target and QA or accuracy standard.
• Working knowledge of InterQual, MCG, ODG, or other evidence-based criteria sets.
• Working knowledge of Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
• Review experience in Diagnostic Imaging, Cardiology, Musculoskeletal, Oncology, Sleep, Genetic Testing, or another HealthHelp program area.
• Multistate (compact) nursing license.
• Experience working remotely.

Benefits

• Full-time, fully remote position.
• Structured new employee orientation on HealthHelp’s clinical guidelines and review platform, followed by a production ramp period with regular QA audits and coaching.
• Productivity is measured in cases per hour; quality is measured through regular QA audits.

Compensation Disclosure

The base salary for this position is:

• $65,000 [LVN/LPN] annually
• $75,000 [RN] annually

This represents the base pay range that we reasonably expect to offer for this position. 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.

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.

How to Apply

Please submit your application, including a resume and optional cover letter, through our careers page.