Remote Nurse: Medical Necessity Review & Authorization

HealthHelp - A WNS Company; Houston (TX); À distance; USD 65 000 - 75 000; Plein temps

Avantages offerts par ce poste

Structured training program

QA coaching and ongoing support

Remote work from the United States

Résumé du poste

HealthHelp, a WNS company, seeks a Clinical Review Nurse for a fully remote role in the United States. You will perform prospective reviews for medical necessity on prior authorization requests across multiple specialty programs and refer non-qualifying cases to Physician Reviewers.

You will operate in a production setting with daily case targets and QA audits, receiving structured training before ramping up to full production with coaching and ongoing support.

Qualifications

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

Responsabilités

• Performs prospective utilization review to determine medical necessity per guidelines and policies.
• Identify clinical indications, criteria met, missing docs; refer non-qualifying requests with summaries.
• Meet productivity and QA standards and complete reviews within required timeframes.
• Document reviews accurately per policy.
• Communicate determinations to providers with professional summaries.
• Assist with escalated/expedited cases and support leadership.

Connaissances

Prior authorization review

Microsoft Office

HIPAA compliance

Production environment

Formation

RN or LVN/LPN nursing program

Outils

InterQual

MCG

OID/criteria sets

Description du poste

HealthHelp, a WNS company, seeks a Clinical Review Nurse for a fully remote role in the United States. You will perform prospective reviews for medical necessity on prior authorization requests across multiple specialty programs and refer non-qualifying cases to Physician Reviewers.

You will operate in a production setting with daily case targets and QA audits, receiving structured training before ramping up to full production with coaching and ongoing support.