Nurse - Clinical Review

Company Overview

HealthHelp, part of WNS and the Capgemini group, operates as an AI-enabled intelligent operations and transformation partner serving a broad client base across healthcare and other industries. The organization combines deep domain expertise with analytics and technology to help businesses improve performance, scale effectively, and deliver lasting results. It operates globally with headquarters across multiple continents, delivery centers in several countries, and a large employee base.

Role Summary

This position is focused on clinical utilization review work. The nurse will assess cases against medical necessity standards, support timely review workflows, handle escalated matters, and coordinate with providers and internal teams to help ensure appropriate care decisions.

Key Duties

• Review cases to confirm whether requests meet medical necessity requirements under the applicable medical policies and client or regulatory standards.
• Handle escalated cases that need additional attention or special processing.
• Complete clinical reviews within the required state, federal, and client-defined turnaround times.
• Work with client contacts to address and resolve concerns.
• Spot quality-related issues and escalate them to UM leadership.
• Support physician reviewers and medical directors so review timelines are met.
• Maintain accurate written records in line with documentation rules.
• Help ensure policies, procedures, and regulatory requirements are applied consistently with nursing leadership.
• Stay updated on compliance and regulation changes communicated by the compliance and nursing teams.
• Follow HIPAA and all relevant state and federal healthcare regulations.
• Provide professional customer service to providers, administrative staff, and other stakeholders.
• Promote a respectful, collaborative, inclusive, and teamwork-driven work environment.
• Communicate by phone with ordering providers, members, internal staff, PCPs, and rendering providers when needed to move reviews forward and support care decisions.
• Use multiple computer systems and software tools to manage cases and document work.
• Support the company’s mission, vision, and business goals.
• Take part in the Quality Management Program when required.
• Follow URAC and NCQA expectations relevant to the position.
• Prioritize work independently, stay effective under pressure, and meet urgent deadlines.
• Explain clinical concepts clearly to providers and staff using the applicable guidelines.
• Perform additional duties and projects as assigned to support business needs.

Qualifications

• Graduate of an accredited nursing program with an RN, LPN, or LVN credential.
• Must hold an active, unrestricted nursing license in a U.S. state or territory.
• At least 1 year of experience in utilization review or utilization management.
• Strong Microsoft Office skills, especially Word, Excel, and PowerPoint, plus the ability to learn new healthcare software and systems.
• Prior exposure to state and federal compliance standards is preferred.
• Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD).
• Understanding of insurance terminology.
• Good organization and time-management ability.
• Strong written and spoken communication skills.
• Ability to apply critical thinking in clinical review situations.
• Self-driven, proactive, and able to work independently or as part of a team.

Schedule and Work Setup

The role is remote. Training runs for the first 6 weeks, Monday through Friday, 8:00 AM to 4:30 PM CST. After training, the regular schedule is 10:30 AM to 7:00 PM CST.

Compensation

The base annual pay is $65,000 for LVN/LPN candidates and $75,000 for RN candidates. Final pay will depend on factors such as location, overall experience, directly relevant experience, education, certifications, industry knowledge, and skills. The role may also qualify for performance bonuses, incentives, or commissions beyond base salary.

Benefits

Medical, dental, and vision coverage are offered, along with a 401(k) plan.

Start Date

Expected start date: 08/03/2026.

Equal Opportunity and Accommodations

WNS is an equal opportunity employer and is committed to maintaining an inclusive workplace. All qualified applicants are considered without regard to protected characteristics under applicable law. Reasonable accommodations are available for individuals with disabilities and sincerely held religious beliefs, including during the application process.

Application

Applicants should submit a resume and may include an optional cover letter through the careers page or by email at [email protected].