Job Description

We're Hiring: Utilization Review Nurse - RN!
We are seeking a dedicated and experienced Utilization Review Nurse (RN) to join our team. The ideal candidate will possess clinical expertise and a strong understanding of healthcare regulations to ensure optimal patient care while managing resource utilization effectively.
Location: 100% remote - but ust be residing and licensed in IL or TX
Role: Utilization Review Nurse - RN
Description
RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan.
This position is responsible for performing accurate and timely medical review of claims suspended for medical necessity, contract interpretation, pricing; and to Initiate and/or respond to correspondence from providers or members concerning medical determinations.
Required Qualification:
Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation.
Awareness of claims processes and claims processing systems.
PC proficiency to include Microsoft Word and Excel and health insurance databases.
Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings.
Organizational skills and prioritization skills.
Registered Nurse (RN) with unrestricted license in state. 3 years clinical experience.

Job Tags

Contract work,

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