Clinical Review Nurse

About the role

Join WNS as a Clinical Review Nurse and perform utilization reviews to ensure medical necessity compliance with client policies and regulatory standards. You will work closely with providers, internal teams, and clients to resolve escalated cases and support quality patient care.

Key responsibilities

• Conduct utilization reviews of cases against medical policies and governing regulations.
• Facilitate resolution of escalated cases requiring special handling.
• Collaborate with client personnel to address customer concerns and refer quality issues to UM Leadership.
• Assist Physician Reviewers and Medical Directors to meet review timeframes.
• Maintain documentation in line with HealthHelp’s policies and ensure regulatory compliance (HIPAA, URAC, NCQA).
• Engage in phone conversations with providers, members, and internal staff to support the clinical review process.
• Utilize computer systems and software to manage cases and document reviews.
• Participate in the HealthHelp Quality Management Program and stay current with regulatory changes.

Required profile

• Ability to prioritize projects, work independently under pressure, and meet critical deadlines.
• Strong communication skills for conveying clinical concepts to providers and staff.
• Commitment to teamwork, respect, diversity, and cooperation.
• Adherence to HIPAA, state, and federal regulations.

Required skills

What we offer

• Opportunity to work within a global leader in intelligent operations and transformation.
• Engagement with a diverse client base across multiple industries.
• Professional development through participation in quality management programs.