What are the responsibilities and job description for the Utilization Review Nurse position at Innovative Systems Group?
This is full-time remote, but candidates must reside in IL or TX
Contract: 12/22/2025 to 03/31/2026
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.
Qualifications:
- 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.
Required Qualification(s)
- RN with IL or TX Active License, must have Utilization experience, familiar with MCG and ASAM criteria.
Preferred Qualification(s)
- Prefer inpatient hospital experience/ER