Remote Nurse: Clinical Utilization Review

HealthHelp - A WNS Company; Houston (TX); On-site; USD 65,000 - 75,000; Full time

Job summary

WNS is seeking a clinically trained reviewer to perform utilization reviews and case management activities. The role requires RN or LVN/LPN licensure and at least two years in related functions, with strong knowledge of regulatory standards and insurance terminology.

The candidate will work remotely, coordinate with providers and clients, and help ensure timely, compliant care decisions while maintaining thorough documentation.

Qualifications

• RN or LVN/LPN license from an accredited school (required).
• Minimum of two years in utilization review, case management, or clinical quality improvement.
• Proficient in Microsoft Office (Word, Excel, PowerPoint) and adaptable to healthcare software.
• Experience with state/federal regulatory and compliance standards preferred.
• Knowledge of insurance terminology is helpful.
• Excellent written and verbal communication skills.
• Ability to work independently, under pressure, and meet deadlines.

Responsibilities

• Performs utilization review to determine medical necessity per policies.
• Facilitates resolution of escalated cases requiring special handling.
• Conducts clinical reviews within state/federal/client timeframes.
• Collaborates with client personnel to resolve concerns.
• Identifies and refers quality issues to UM Leadership.
• Supports Physicians and Medical Directors to ensure review compliance.
• Maintains documentation per HealthHelp policy.
• Ensures regulatory requirements are followed with Nursing Management.

Skills

Utilization review

Case management

Regulatory knowledge

MS Office

Communication skills

Education

RN or LVN/LPN license

Tools

Microsoft Office

Healthcare software

Job description

WNS is seeking a clinically trained reviewer to perform utilization reviews and case management activities. The role requires RN or LVN/LPN licensure and at least two years in related functions, with strong knowledge of regulatory standards and insurance terminology.

The candidate will work remotely, coordinate with providers and clients, and help ensure timely, compliant care decisions while maintaining thorough documentation.