Responsibilities
- 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
Requirements
- RN graduate from an accredited school of nursing (BSN preferred)
Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent)
Two (2) years of experience in an acute care setting, required
Two (2) years of inpatient clinical nursing, utilization management, concurrent experience required
Experience with InterQual or similar evidence-based clinical decision support criteria, preferred
Willingness to complete and maintain InterQual certification and ongoing competency requirements
Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning,
Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements
Knowledge of insurance terminology
Experience working with state and federal regulatory and compliance standards, preferred
Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required
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
About HealthHelp
WNS Healthhelp, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries, including Banking and Financial Services, Healthcare, Insurance, Shipping and Logistics, and Travel and Hospitality. We bring together deep domain excellence - WNS’ core differentiator - with AI-powered platforms and analytics to help businesses innovate, scale, adapt and build resilience in a world defined by disruption. Our purpose is clear: to enable lasting business value by designing intelligent, human-led solutions that deliver sustainable outcomes and a differentiated impact. With three global headquarters across four continents, operations in 13 countries, 65 delivery centers and more than 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.
