Nurse - Clinical Review

WNS, 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.

The Clinical Review Nurse makes prospective medical necessity determinations on prior authorization requests for Health Help's specialty programs, including Diagnostic Imaging, Cardiology, Musculoskeletal, Physical Medicine, Sleep, Oncology, and Genetic Testing. Reviewers apply Health Help'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 Health Help'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 Health Help'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 time frames.
• Documents each review accurately and completely according to Health Help'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 time frames.
• Identifies and refers potential quality-of-care concerns to UM Leadership.
• Participates in the Health Help 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.

Required

• Graduate of an accredited RN or LPN/LVN nursing program.
• Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.
• Minimum of two (2) years of experience reviewing prior authorization or utilization review requests against clinical criteria (e.g., prior authorization, pre-service review, precertification, or utilization…