Interqual Jobs in Texas (NOW HIRING)

Company Description

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.

Job Description

 Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including: 
 Admission reviews
 Continued stay reviews
 Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital)
 Related follow-up activities and documentation updates
 Engage in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions
 Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions
 Facilitates resolution of escalated cases that may require special handling
 Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines
 Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes
 Maintains written documentation according to HealthHelp's documentation policy
 Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations
 Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs
 Complies with URAC & NCQA standards or other requisite regulating bodies
 Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management
 Keeps current with regulation changes as provided by Compliance Department and Nursing Management
 Functions as subject matter expert to support Compliance Department initiatives and updates
 Collects and enters confidential information ensuring the highest level of confidentiality in all areas
 Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times
 Maintains availability to support concurrent review coverage requirements, which may include non-standard  business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes
 Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines
 Appropriately identifies and refers quality issues to UM Leadership
 Collaborates with client personnel to resolve customer concerns
 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
 Promotes business focus which demonstrates an understanding of the company's vision, mission, and strategy
 Participates in the HealthHelp Quality Management Program, as required
 Performs other related duties and projects as assigned to meet business needs

Qualifications

 RN graduate from an accredited school of nursing (BSN preferred)
 Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent)
 Two (2) years of experience in an acute care setting, required
 Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred
 Experience with InterQual or similar evidence-based clinical decision support criteria, preferred
 Willingness to complete and maintain InterQual certification and ongoing competency requirements
 Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred
 Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements
 Knowledge of insurance terminology
 Experience working with state and federal regulatory and compliance standards, preferred
 Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required
 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 efficiently and independently, or as a team member
 

Additional Information

The base salary for this position is $75,000 annually. This represents the base pay range that we reasonably expect to offer for this position.

In addition to base pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed base salary range.

WNS complies with all applicable federal, state, and local pay transparency laws, including those in California, Colorado, New York, Washington, and Illinois.

Note: For complete compensation information, please refer to the job posting on our official careers page.

Benefits Overview

Our benefits package includes (but is not limited to):

- Medical, dental, and vision insurance

- Paid time off (PTO), holidays, and sick leave

- 401(k) with company match or other retirement plan

- Life and AD&D Insurance

- Employee Assistance Program

SCHEDULE

7AM - 5PM PST / 9AM - 7PM CST Monday- Friday while you should remain flexible based on business needs. 

Start Date: Mid August
Location: 100% remote
Equipment: Provided (mini desktop, dual monitors, mouse, keyboard, headset)
Attendance: 100% attendance required for first 90 days.

Equal Opportunity Employer Statement

WNS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other status protected under federal, state, or local law.

We also provide reasonable accommodations to individuals with disabilities and for sincerely held religious beliefs in all aspects of employment, including the application process.

WNS HealthHelp (A Capgemini Company) provides cutting-edge technology to streamline the review process, including our proprietary HIPAA - compliant portal and Physician App, ensuring efficiency and ease of use for our specialists.

WNS HealthHelp (A Capgemini Company) is an Equal Opportunity Employer. At WNS HealthHelp, we celebrate diversity and are committed to creating an inclusive environment that extends to our suppliers and vendors. All qualified Independent Contractors will receive consideration without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other status protected under federal, state, or local law.