Remote Nurse Team Lead, Utilization Review

HealthHelp, LLC; Houston (TX); À distance; USD 75 000 - 85 000; Plein temps

Avantages offerts par ce poste

Medical insurance

PTO/Holidays/Sick leave

401(k) plan with company match

Life and AD&D Insurance

Employee Assistance Program

Résumé du poste

WNS, part of Capgemini, is seeking a Clinical Review Team Lead to serve as the clinical expert for prospective utilization review. The role balances production reviews with lead duties, coaching nurses, and ensuring timely case flow in a fast-paced environment.

The ideal candidate is analytical, highly organized and experienced in utilization management, with strong communication for cross-functional collaboration and regulatory compliance.

Qualifications

• Graduate of an accredited school of nursing.
• Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.
• Minimum of three (3) years of prospective utilization management experience making medical necessity determinations.

Responsabilités

• Serves as clinical SME for assigned programs and modalities, answering criteria, guideline and process questions.
• Performs prospective case reviews while maintaining productivity and quality standards.
• Handles complex, escalated and expedited cases and provider inquiries.
• Interprets clinical guidelines and client policies; identifies gaps for Nursing Management.
• Coordinates daily physician reviewer case flow and notifications.

Connaissances

Analytical skills

High attention to detail

Effective communication

Formation

RN/LPN/LVN license

Outils

Microsoft Office (Outlook, Excel, Word, PowerPoint)

AVAYA

ADP Workforce Now

Description du poste

WNS, part of Capgemini, is seeking a Clinical Review Team Lead to serve as the clinical expert for prospective utilization review. The role balances production reviews with lead duties, coaching nurses, and ensuring timely case flow in a fast-paced environment.

The ideal candidate is analytical, highly organized and experienced in utilization management, with strong communication for cross-functional collaboration and regulatory compliance.