Utilization Review Nurse - RN

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.