Nurse - Clinical Review

•    Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body. 

•    Facilitates resolution of escalated cases that may require special handling.

•    Performs clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes.  

•    Collaborates with client personnel to resolve customer concerns.

•    Appropriately identifies and refers quality issues to UM Leadership.

•    Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.

•    Maintains written documentation according to HealthHelp’s documentation policy.

•    Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.

•    Keeps current with regulation changes as provided by Compliance Department and Nursing Management.

•    Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs.

•    Provides quality customer service through interaction with providers, administrative staff, and others.

•    Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others.

•    Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions.

•    Effectively utilizes various computer systems and software to manage cases and document reviews.

•    Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy.

•    Participates in the HealthHelp Quality Management Program, as required.

•    Adheres to both URAC & NCQA standards pertinent to their job description.

•    Ability to prioritize projects, work independently under pressure, and meet critical deadlines.

•    Capable of communicating clinical concepts to providers and staff based on guidelines.

•    Performs other related duties and projects as assigned to meet business needs.

Function: Production
Experience Level: Entry Level