Nurse, Concurrent Review

Company Overview

WNS, a part of Capgemini, is a leader in AI-powered intelligent operations and transformation, serving over 700 clients across various industries such as Banking, Healthcare, Insurance, and Logistics. Operating worldwide with more than 66,000 employees, WNS combines domain expertise with technology to create impactful solutions.

Job Responsibilities

• Conduct concurrent inpatient utilization reviews using InterQual criteria to assess medical necessity, including admission, continued stay, and transitional care reviews across various care facilities.
• Collaborate clinically with attending physicians and care teams to gather information, discuss medical necessity, and support appropriate care decisions.
• Communicate clinical reasoning during real-time reviews and manage complex or escalated cases as needed.
• Refer cases to Physician Reviewers or Medical Directors following guidelines and assist in ensuring compliance with review timeframes.
• Keep thorough documentation compliant with HealthHelp policies and maintain knowledge of regulatory and payer-specific requirements.
• Adhere strictly to HIPAA, state, federal regulations, and accreditation standards like URAC & NCQA.
• Stay updated on policy changes and support compliance initiatives as a subject matter expert.
• Handle confidential information with the utmost discretion and perform expedited reviews as required.
• Support coverage needs including non-standard hours, prioritize tasks, meet deadlines, and manage multiple projects independently.
• Identify quality issues for leadership, collaborate to resolve customer concerns, foster teamwork, respect diversity, and promote company vision and strategy.
• Participate in quality management programs and perform additional duties as assigned.

Qualifications

• Registered Nurse with diploma from an accredited program; BSN is preferred.
• Active unrestricted RN license in the U.S. state or territory (USRN equivalent acceptable).
• Minimum two years of acute care experience; inpatient clinical nursing or utilization management experience preferred.
• Familiarity with InterQual or similar clinical decision tools, and willingness to maintain certification.
• Knowledge of medical necessity criteria, inpatient versus observation status, transitional care planning, payer requirements, and insurance terminology.
• Experience with regulatory compliance standards preferred.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint).
• Strong organizational, communication, and critical thinking skills with ability to work independently or as a team member.

Compensation and Benefits

The estimated base salary for this role is $75,000 annually, subject to variation based on candidate qualifications, experience, and location. Additional performance-based incentives may be offered.

Benefits include medical, dental, and vision insurance; paid time off and holidays; 401(k) retirement plan with company match; life and AD&D insurance; and employee assistance programs.

Equal Opportunity Employer

WNS is committed to diversity and inclusion and provides equal employment opportunities to all qualified individuals without discrimination. Reasonable accommodations are offered for disabilities and religious beliefs throughout the employment process.

Additional Information

This position is remote-based, supported by advanced technology platforms ensuring confidentiality and efficient workflow. Candidates must be able to manage non-standard work hours according to client needs.