Full-Time Nurse - Clinical Review

Performs utilization review of cases to determine medical necessity in accordance with client and governing body policies.

Facilitates resolution of escalated cases needing special handling.

Conducts clinical reviews following HealthHelp policies and procedures within specified timeframes.

Collaborates with client personnel to resolve customer concerns.

Identifies and refers quality issues to UM Leadership.

Assists physician reviewers and medical directors to ensure compliance with review timeframes.

Maintains written documentation according to HealthHelp policy.

Ensures consistency in policy, procedure, and regulatory implementation with nursing management.

Keeps current with regulation changes from Compliance and Nursing Management.

Adheres to HIPAA, state, and federal regulations pertaining to clinical programs.

Provides quality customer service to providers, administrative staff, and others.

Creates a positive work environment fostering teamwork, respect, diversity, and cooperation.

Engages in phone conversations with providers, members, staff, and PCPs to facilitate clinical reviews and appropriate care decisions.

Effectively utilizes computer systems and software for case management and documentation.

Demonstrates understanding of company vision, mission, and strategy.

Participates in HealthHelp Quality Management Program as required.

Adheres to URAC & NCQA standards.

Prioritizes projects, works independently under pressure and meets deadlines.

Communicates clinical concepts to providers and staff based on guidelines.

Performs other related duties and projects as assigned.

1. RN, LPN/LVN graduate from an accredited school of nursing
2. Current, active unrestricted RN, LPN/LVN license in the U.S.
3. Minimum of two (2) years clinical experience and/or in an administrative role
4. Experience in utilization review, case management, or clinical quality improvement, preferred
5. Proficient in Microsoft Office (Word, Excel, PowerPoint), adapting to new healthcare software.
6. Experience with state and federal regulatory and compliance standards, preferred
7. Working knowledge of NCD and LCD
8. Knowledge of insurance terminology
9. Strong organizational and time management skills
10. Excellent written and verbal communication skills
11. Utilizes critical thinking skills
12. Highly motivated, self-starter who can work independently or as a team member

Equal Opportunity Employer

Contact talent@healthhelp.com for accommodation requests.

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