Remote Clinical Review Nurse – Prior Authorization

HealthHelp, LLC; Houston (TX); Remote; USD 65,000 - 75,000; Full time

Job summary

WNS, part of Capgemini, is seeking a Clinical Review Nurse for a fully remote, full-time role. You will perform prospective utilization reviews for HealthHelp’s programs, applying clinical guidelines and policies to decide medical necessity.

Successful candidates will complete structured training and work toward production targets with QA oversight. The role requires an RN or LPN license, at least two years of prior authorization review experience, and strong documentation skills.

Qualifications

• Graduate of an accredited RN or LPN/LVN nursing program.
• Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.
• Minimum of two years of experience reviewing prior authorization or utilization review requests.
• Ability to work in a production environment with daily productivity and quality standards.
• Accurate, efficient typing and clinical documentation skills.
• Proficiency in Microsoft Office and the ability to learn new healthcare software.
• Reliable high-speed internet and a private, HIPAA-compliant home workspace.

Responsibilities

• Performs prospective utilization review of prior authorization requests to determine medical necessity.
• Identifies clinical indication, criteria met or not, and missing documentation; approves or refers with summary.
• Maintains productivity and QA standards; completes reviews within timeframes.
• Documents reviews per HealthHelp policy.
• Communicates with providers and office staff to obtain additional information.

Skills

RN license

LPN/LVN license

Prior authorization experience

Remote work readiness

Microsoft Office proficiency

Education

RN or LPN/LVN nursing program

Tools

Microsoft Office

HIPAA-compliant systems

Job description

WNS, part of Capgemini, is seeking a Clinical Review Nurse for a fully remote, full-time role. You will perform prospective utilization reviews for HealthHelp’s programs, applying clinical guidelines and policies to decide medical necessity.

Successful candidates will complete structured training and work toward production targets with QA oversight. The role requires an RN or LPN license, at least two years of prior authorization review experience, and strong documentation skills.