Concurrent Inpatient Review Nurse

At WNS HealthHelp (A Capgemini Company), our mission is to collaborate with payors and providers to improve patient safety and deliver quality care through an evidence-based, educative, and collaborative model, focused on improving outcomes and reducing healthcare costs. We’re revolutionizing healthcare delivery by ensuring patients receive the most appropriate, cost-effective care while supporting healthcare providers in their decision-making process.

SCHEDULE: 7AM – 5PM PST/9AM – 7PM CST Monday- Friday while you should remain flexible based on business needs which could include weekends or alternative daytime hours.

Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including: Admission reviews Continued stay reviews Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital) Related follow-up activities and documentation updates Engage in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions Facilitates resolution of escalated cases that may require special handling Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes Maintains written documentation according to HealthHelp’s documentation policy Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs Complies with URAC & NCQA standards or other requisite regulating bodies 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 Functions as subject matter expert to support Compliance Department initiatives and updates Collects and enters confidential information ensuring the highest level of confidentiality in all areas Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines Appropriately identifies and refers quality issues to UM Leadership Collaborates with client personnel to resolve customer concerns 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 Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy Participates in the HealthHelp Quality Management Program, as required Performs other related duties and projects as assigned to meet business needs