Remote Clinical Reviewer — Utilization Management

HealthHelp, LLC; United States; Remote; USD 65,000 - 75,000; Full time

Benefits offered by this job

Remote work

Full-time position

Training program

Job summary

WNS Healthhelp, part of Capgemini, is seeking a qualified RN/LPN/LVN with utilization review experience for a remote full-time role in the United States. You will review cases for medical necessity, collaborate with providers and client staff, and ensure timely, compliant documentation.

The role emphasizes adherence to HIPAA, state and federal regulations, and strong communication. Training will be provided, and a competitive salary with potential bonuses is offered.

Qualifications

• Active RN/LPN/LVN license in the U.S.
• Minimum of two (2) years experience in utilization review or utilization management.
• Proficient with Microsoft Office and adaptable to healthcare-specific software and systems.

Responsibilities

• Performs utilization review to determine medical necessity per medical policies.
• Facilitates resolution of escalated cases requiring special handling.
• Performs clinical reviews within defined timeframes and policies.
• Collaborates with client personnel to resolve customer concerns.
• Maintains documentation per HealthHelp policy and HIPAA requirements.
• Ensures compliance with URAC and NCQA standards.

Skills

RN license

LPN/LVN license

Utilization review

Microsoft Office

Regulatory compliance

Communication skills

Education

RN/LPN/LVN nursing degree

Tools

Healthcare software systems

Job description

WNS Healthhelp, part of Capgemini, is seeking a qualified RN/LPN/LVN with utilization review experience for a remote full-time role in the United States. You will review cases for medical necessity, collaborate with providers and client staff, and ensure timely, compliant documentation.

The role emphasizes adherence to HIPAA, state and federal regulations, and strong communication. Training will be provided, and a competitive salary with potential bonuses is offered.