Nurse – Clinical Review

• Perform utilization review of cases to determine whether requests meet medical necessity criteria
• Facilitate resolution of escalated cases requiring special handling
• Perform clinical reviews according to HealthHelp policies, procedures, and applicable timeframes
• Collaborate with client personnel to resolve customer concerns
• Identify and refer quality issues to UM Leadership
• Assist Physician Reviewers and Medical Directors as necessary
• Maintain written documentation according to policy
• Ensure consistency with policy, procedure, and regulatory requirements
• Keep current with regulation changes
• Adhere to HIPAA, state, and federal regulations
• Provide quality customer service to providers, administrative staff, and others
• Engage in phone conversations with providers, members, internal staff, PCPs, and rendering providers
• Use computer systems and software to manage cases and document reviews
• Participate in the HealthHelp Quality Management Program
• Adhere to URAC and NCQA standards
• Prioritize projects, work independently under pressure, and meet critical deadlines
• Communicate clinical concepts to providers and staff based on guidelines
• Perform other related duties and projects as assigned

• RN, LPN/LVN graduate from an accredited school of nursing
• Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S.
• Minimum of two (2) years experience in utilization review, case management, or clinical quality improvement
• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint)
• Ability to adapt to new healthcare-specific software and systems
• Experience working with state and federal regulatory and compliance standards, preferred
• Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD)
• Knowledge of insurance terminology
• Good organizational and time management skills
• Excellent written and verbal communication skills
• Ability to utilize critical thinking skills
• Highly motivated, self-starter who can work efficiently and independently, or as a team member

• Performance-based bonuses, incentive pay, or commissions may be available in addition to base pay
• Remote work
• Reasonable accommodations for individuals with disabilities and sincerely held religious beliefs
• Inclusive work environment
• Training schedule and regular schedule specified