Clinical Rules Nurse

  • 16945 Northchase Dr, Houston, TX 77060, USA
  • Employees can work remotely
  • Full-time

Company Description

HealthHelp - A WNS Company (www.HealthHelp.com), is the leader in the field of healthcare utilization & care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that better inform physicians, and ensures quality and safety for the patients needing treatment.

HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth.

Our specialty benefits management services are broad and include, Cardiology, Oncology, Radiology, Radiation Therapy, Sleep Care, and Musculoskeletal Care. HealthHelp has two locations in Houston, one a corporate office and the second a state-of-the art contact center. HealthHelp is also proud to have another such contact center in Albany, New York.

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.

Job Description

Overview

The Clinical Content department includes the teams responsible for development and publishing of HealthHelp clinical guidelines, and the clinical rules that help automate Tier 1 utilization review of prior authorization requests.  The team collaborates with product management, physician review, utilization management, quality, education, and IT teams to deliver the clinical guidance and automation that brings value to our payer customers, and revenue to HealthHelp.

 

In the Clinical Rules team, we convert the clinical guideline content into interactive criteria controlled by a clinical rules engine and a web-based prior authorization entry application.  The prior authorization application, called WebConsult, is used by our health plan customer’s provider members to enter their prior authorization requests for those specialty care procedures managed by HealthHelp.  Clinical rules help automate approvals in real-time, or route requests for clinical review when criteria is not met.

 

The Clinical Rules team is looking for nurses who can work with Physician content editors to synthesize the guideline content into the criteria used in rules and surfaced to providers in WebConsult.  This requires experience with clinical content and prior authorization processes to understand the right mix of criteria and decision logic that will be most effective for the end user requestor, and medical necessity intent of clinical content.

 

MAJOR RESPONSIBILITIES

 

·         Build the clinical criteria logic, based on clinical guideline content, and the most direct path to a medical necessity approval or clinical review hand-off

·         Work directly with Physician staff and data analytics to identify the best criteria strategy for a procedure. 

·         Document the criteria logic as the beginning step in the process of clinical rules production, and work directly with those building the rules to ensure the correct logic is surfaced in the WebConsult application.

·         Collaborate with Clinical Guidelines and Product Management teams in response to new clinical content that will require new clinical rules.  This will require you to participate in and lead change control initiatives for the release of new rule sets.

·         Analyzes program processes and makes recommendations for improving efficiency, resulting in expense reduction both internally and for external clients.

·         Resolves and/or escalate issues in a timely fashion.

 

Qualifications

·         3+ years in utilization management nursing

·         2+ years implementation experience with prior authorization, care management, or claims management applications.

·         Proficient at documenting software requirements, and using MS Excel to document decision logic

·         Excellent interpersonal and customer service skills, with the ability to communicate efficiently with individuals at all seniority or C-Suite levels

·         Strong analytical and critical thinking skills. Ability to obtain, manipulate, and interpret various reports and data to produce meaningful information

1+ year of experience with evidence-based guidelines

·         Proven project management, task management and execution management skills

·         Experience working in cross functional and matrixed management operating teams

·         Proven ability to succeed in a fast paced and highly ambiguous business environment with short deadlines

·         Experience with SQL querying is a plus

Additional Information

All your information will be kept confidential according to EEO guidelines.

 

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