Utilization Management Nurse Reviewer
- 16945 Northchase Dr, Houston, TX 77060, USA
- Employees can work remotely
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.
WNS Philippines - Established in 2008, WNS Philippines has been delivering the full spectrum of BPM services – in customer interaction services, finance and accounting, research and analytics, technology solutions and industry-specific businesses for more than 10 years. With more than 8,000 employees spread across 11 sites located in 4 key cities, Quezon City, Pasig City, Muntinlupa City, and Iloilo City – WNS is one of the fastest growing centers in the country.
Why Join Us?
At WNS, our mission is to enable clients to outperform with our passion for service and innovation. At the heart of each client engagement is our pursuit to understand our client’s business, and create impactful solutions that can drive agility and excellence into their business processes. Our promise of outperformance stems from our deep domain expertise, partnership approach and a global delivery network.
Our mission as an organization is guided by our CIRCLE of values: Client First, Integrity, Respect, Collaboration, Learning, Excellence.
We promise our employees to experience role clarity, coaching and mentoring, professional development and structured career path through our 5 people promises and keeping employee experience at the core. Experience the culture of outperformance, engagement, celebration and enjoy wide variety of best in class benefits including free HMO coverage for self and dependent from Day 1; Also contribute to society through our WNS Cares Foundation, where you have the opportunity to support meaningful initiatives and make an impact in the community.
· 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)
All your information will be kept confidential according to EEO guidelines.