Nurse Utilization - Review Nurse

• This is full time remote, but candidates must reside in the either of the five business plans: IL, TX, NM, MT,TN or OK
• 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.

• 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 with at least
• 2 years within the hospital setting or direct patient care.

Salary : $41 - $42