Nurse - Clinical Review

The Clinical Review Nurse makes prospective medical necessity determinations on prior authorization requests for HealthHelp’s specialty programs, including Diagnostic Imaging, Cardiology, Musculoskeletal, Physical Medicine, Sleep, Oncology, and Genetic Testing. Reviewers apply HealthHelp’s proprietary, evidence-based clinical guidelines, approve requests that meet criteria, and refer those that do not to Physician Reviewers.

This is a full-time, fully remote, production-based role. Reviewers work to daily productivity (cases per hour) and quality (QA audit) standards. New reviewers complete structured training on HealthHelp’s guidelines and systems, then move into production with a supported ramp period.

MAJOR RESPONSIBILITIES

• Performs prospective utilization review of prior authorization requests to determine whether each request meets medical necessity criteria under HealthHelp’s clinical guidelines, client medical policies, and applicable state and federal requirements.
• Identifies the clinical indication, the criteria met or not met, and any missing documentation; approves requests that meet criteria and refers those that do not to Physician Reviewers with a clear, concise clinical summary.
• Meets established productivity (cases per hour) and quality (QA audit) standards, and completes reviews within state, federal, and client turnaround timeframes.
• Documents each review accurately and completely according to HealthHelp’s documentation policy.
• Contacts ordering and rendering providers, office staff, and members to obtain additional clinical information and communicate determinations professionally.
• Handles escalated and expedited cases that require special handling.
• Supports Physician Reviewers and Medical Directors to keep cases moving within review timeframes.
• Identifies and refers potential quality-of-care concerns to UM Leadership.
• Participates in the HealthHelp Quality Management Program, including QA audits and calibration, and applies feedback to improve accuracy.
• Keeps current with guideline, policy, and regulatory updates from the Compliance Department and Nursing Management, and adheres to URAC, NCQA, HIPAA, and state and federal requirements.
• Works in multiple computer systems at the same time to manage cases and document reviews.
• Collaborates with client personnel and internal teams to resolve concerns, and contributes to a team environment of respect, cooperation, and inclusion.
• Performs other related duties and projects as assigned to meet business needs.

Function: Production
Experience Level: Entry Level