Utilization Review Nurse

Innovative Systems Group; Richardson (TX); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare organization is seeking a full-time remote RN responsible for validating medical necessity in the insurance industry. This role involves performing medical reviews on claims and requires a nursing license, alongside experience in claims processing and knowledge of accreditation standards. Candidates must reside in IL or TX and possess strong communication skills to interact with providers and members.

Qualifications

• Knowledge of URAC, NCQA standards, and health insurance legislation.
• Awareness of claims processes and systems.
• 3 years of clinical experience required.

Responsibilities

• Validate the medical necessity of treatment plans.
• Perform medical review of claims for medical necessity.
• Communicate findings to physicians and providers.

Skills

Knowledge of accreditation

Claims processing

PC proficiency

Communication skills

Organizational skills

Education

Registered Nurse (RN) license

Tools

Microsoft Word

Microsoft Excel

Health insurance databases

Job description

3 days ago Be among the first 25 applicants

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.