Utilization Review Nurse

Job Title: Utilization Review Nurse
Job Location: Fully Remote must reside in -Richardson, TX/IL
Job Duration: 3-4 Months (possibility of extension)
Shift: Monday - Friday, 8:00am - 5:00pm 
Payrate: $39.20 - $41.45/ hr. on w2
 
Job Summary:

• 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.
• Awareness of claims processes and claims processing systems.

Required Qualifications:

• Bachelor’s degree OR 4 years of healthcare experience.
• Minimum 5 years of experience in utilization management, appeals, claims, or mainframe systems.
• Experience in health operations and customer relations.
• Knowledge of managed care processes.
• Familiarity with NCQA and URAC accreditation standards.
• Understanding of state and federal healthcare regulations.
• Strong time-management skills.
• Appeals and/or Utilization Management experience.
• 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.