Manager, Clinical Review
- 16945 Northchase Dr, Houston, TX 77060, USA
- Employees can work remotely
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 We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach.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.
This role receives request reviews, denial decisions and documentation, and Member/Provider communication, and prepares letters communicating health care decisions to members/providers. The clinician is well-versed in health plan/insurance knowledge, possesses business know-how, and exhibits high level skills and communication to analyze the Member’s clinical medical and health status to evaluate denial determinations and assist in the resolution for prior authorization and retrospective requests for denied services.
This position will ensure that all contractual and regulatory requirements are met, and all clinical review protocols are adhered to, in accordance with Utilization Management Policies and procedures, and all notification of determinations and appeal outcomes are complete, accurate, and communicated verbally and in no greater than fourth grade reading levels. This position is very independent, will be responsible to apply clinical judgement within the scope of his/her license, and must be able to self-manage tasks and time based on defined turnaround times and client regulations.
From time to time, the UM Denial & Appeals Review Nurse may be asked to support with the clinical review of UM cases and/or participate in special projects such as but not limited to process improvement initiatives, user acceptance testing or system design/enhancement workgroups.
• System specialist related to documentation, workflow, and process for health plan/insurance request reviews; Perform complete, accurate and consistent reviews for requests, data entry into system software applications in accordance with policies, procedures and instruction from management;
• Provides fact-based information on a regular basis on clinical denial performance with recommendations on process improvements to avoid denials in the future;
• Create and maintain accurate documentation, records, accounts of action, denials, appeals, and other assigned work to contributed to reviews, reports, internal and external audits, and any other EXL business need;
• Works with the Leadership to identify training and system gaps and develop strategies to address these gaps;
• Answer inbound calls timely, working directly with members and/or providers regarding inquiries involving authorizations;
• Identify authorization requests for line-of-business, urgency level, type of service, and assess for complete/incomplete record submission;
• Coordinate appeal process and maintain appropriate follow-up on appealed claims and contact information;
• Demonstrates thorough knowledge of third party payers’ EOB’ s (Explanation of Benefits) and understand specific time limitations for appeals for all served lines of business;
• Facilitate processing of authorization determination letters including approval, denial, partially denied/approved, administrative denial, and other required notices to providers and members within regulatory processing timeframes;
• Reviews escalated and expedited requests; Researches case histories, past decisions, system documentation, regulatory codes/rules/statutes/guides, and internal policies to develop and respond to inquiries, complaints, concerns, client and Member requests thoroughly, accurately, and ensuring compliance with all regulatory and internal standards/guidelines;
• Identifies high risk and high cost/complex patients for referral to case management;
• Serve as a clinical resource to other in regards to UM review protocols and interpretation of clinical information.
• Ensures that external requests for peer to peer conversations between external physicians and physician reviewers are documented, scheduled and coordinated, in accordance with protocols for peer to peer reviews, and that outcomes of these discussions are documented and effectuated appropriately.
• Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services. Contact third party payers, insurance medical directors, case management, and utilization review related to reconsiderations, peer to peer offerings, and/or appeal reviews, including post-service and claims appeals requiring clinical intervention. Contact may be by phone, fax, written, and/or in person.
• Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues.
• Other duties as assigned
• Current and unrestricted Registered Nurse license in appropriate state(s) and willing to obtain state specific licensing, as required.
• Graduated from an accredited nursing institution with a minimum of an Associate’s Degree, required.
• Bachelor’s Degree in any healthcare-related, administrative, or service-type degree, preferred.
• 5 years of clinical nursing, required.
• 3 years of managed care or health plan experience, required.
• 1 year of denial and/or appeal review experience, required.
• Knowledge of evidence-based clinical guidelines, as well as, knowledge of third party payer regulations related to utilization and quality review, preferred.
All your information will be kept confidential according to EEO guidelines.