Remote Nurse: Clinical Utilization Review

HealthHelp, LLC; Houston (TX); A distancia; USD 65.000 - 75.000; Jornada completa

Descripción de la vacante

WNS is seeking an RN/LPN licensed clinician for usage review and case management. The role focuses on medical necessity determinations, regulatory compliance, and collaboration with providers to ensure quality patient care. The position emphasizes adherence to HIPAA and internal policies while maintaining thorough documentation.

The selected candidate will work remotely with a team, support clinical reviews across states, and contribute to continuous quality improvement under HealthHelp policies.

Formación

• RN or LPN/LVN license required and active in the U.S.
• Minimum of two years in utilization review, case management, or clinical quality improvement
• Proficient in Microsoft Office and ability to adapt to healthcare software/systems
• Experience with state and federal regulatory standards preferred
• Excellent written and verbal communication skills
• Strong organizational and time-management abilities

Responsabilidades

• Performs utilization review of cases to determine medical necessity according to policies
• Facilitates resolution of escalated cases requiring special handling
• Performs clinical reviews within state/federal or client timeframes
• Collaborates with client personnel to resolve concerns
• Maintains documentation per HealthHelp policy and regulatory requirements
• Engages with providers and staff to ensure appropriate care decisions

Descripción del empleo

WNS is seeking an RN/LPN licensed clinician for usage review and case management. The role focuses on medical necessity determinations, regulatory compliance, and collaboration with providers to ensure quality patient care. The position emphasizes adherence to HIPAA and internal policies while maintaining thorough documentation.

The selected candidate will work remotely with a team, support clinical reviews across states, and contribute to continuous quality improvement under HealthHelp policies.