Nurse - Clinical Review

The Clinical Review Nurse makes prospective medical necessity determinations on prior authorization requests for HealthHelp’s specialty programs, including Diagnostic Imaging, Cardiology, Musculoskeletal, Physical Medicine, Sleep, Oncology, and Genetic Testing. Reviewers apply HealthHelp’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 HealthHelp’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 HealthHelp’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 timeframes. Documents each review accurately and completely according to HealthHelp’s documentation policy. Contacts ordering and renderin