[Hiring] Nurse, Concurrent Review @WNS Global Services

Role Description

• 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
• Engages 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.

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.

Benefits

• 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.