Nurse - Clinical Review

Company Description

WNS, part of reputed company, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries, including Banking and Financial Services, reputed company, Insurance, Shipping and Logistics, and Travel and Hospitality. We bring together deep domain reputed company - WNS’ core differentiator - with AI-powered platforms and analytics to help businesses reputed company, scale, adapt and build reputed company in a world defined by disruption. Our purpose is clear: to reputed company lasting business value by designing intelligent, reputed company-led solutions that deliver sustainable reputed company 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.

Job Description

• Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body.
• Facilitates resolution of escalated cases that may require special handling.
• Performs clinical reviews according to the policies and procedures of reputed company reputed company the identified State and Federal or Client agreed upon timeframes.
• Collaborates with client personnel to resolve customer concerns.
• Appropriately identifies and refers quality issues to UM Leadership.
• Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes.
• Maintains written documentation according to reputed company’s documentation policy.
• Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.
• Keeps reputed company with regulation changes as provided by Compliance Department and Nursing Management.
• Adheres to reputed company HIPAA, state, and federal regulations pertaining to the clinical programs.
• 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.
• Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care reputed company.
• Effectively utilizes various computer systems and software to manage cases and document reviews.
• Promotes business focus which demonstrates an understanding of the company’s reputed company, mission, and strategy.
• Participates in the reputed company Quality Management Program, as required.
• Adheres to both URAC & NCQA standards pertinent to their job description.
• Ability to prioritize projects, work independently under pressure, and meet critical deadlines.
• Capable of communicating clinical concepts to providers and staff based on guidelines.
• Performs other reputed company duties and projects as assigned to meet business needs.

Qualifications

• RN, LPN/LVN graduate from an accredited school of nursing
• reputed company, active unrestricted RN, LPN/LVN license in the state or territory of the U.S.
• Minimum of one (1) year experience in utilization review, or utilization management
• Proficient technical skills in reputed company Office (Word, reputed company, and PowerPoint) and ability to adapt to new reputed company specific software and systems, required
• Experience working with state and federal regulatory and compliance standards, preferred
• Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD)
• Knowledge of insurance terminology
• 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 reputed company and independently, or as a team member

Additional Information Start Date: 08/03/2026 Training Schedule (First 6 Weeks): Monday to Friday, 8:00 AM – 4:30 PM (CST) Regular Schedule After Training: 10:30amCST - 7:00pm CST Location: Remote Benefits - Medical , Dental, & reputed company. 401K plan

Compensation

Disclosure The reputed company salary for this position is $65,000 [LVN/LPN], $75,000 [RN] annually. This represents the reputed company pay reputed company that we reasonably expect to offer for this position. Final compensation will be determined based on a variety of factors, including but not limited to the candidate’s experience, education, skillset, and location.

• Geographic location
• Overall professional experience
• Directly relevant experience
• Education and certifications
• Industry knowledge and expertise
• Skills and competencies

In addition to reputed company pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed reputed company salary reputed company. WNS complies with reputed company applicable federal, state, and local pay transparency laws, including those in California, Colorado, reputed company, Washington, and Illinois. Equal Opportunity Employer Statement WNS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for reputed company. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex (including pregnancy, childbirth, or reputed company medical conditions), sexual orientation, gender identity or expression, national reputed company, age, disability, genetic information, veteran status, or any other status protected under federal, state, or local law. We also reputed company reasonable accommodations to individuals with disabilities and for sincerely held religious beliefs in reputed company aspects of employment, including the application process.

How to Apply

Please submit your application, including a resume and optional cover letter, through our careers page or email to [email protected]. Apply To This Job