Utilization Review Nurse

Innovative Systems Group; Richardson (TX); Remote; USD 86,000 - 105,000; Full time

Job summary

A leading company in the insurance industry is seeking a Utilization Review Nurse for a remote position requiring residency in Illinois or Texas. The RN will conduct reviews of medical claims, ensuring compliance with standards while utilizing strong organizational and communication skills. This role offers a competitive salary along with the opportunity for extension beyond the initial duration.

Qualifications

• 3 years clinical experience required.
• Knowledge of URAC, NCQA standards and health insurance legislation.
• Must reside in IL or TX.

Responsibilities

• Perform medical review of claims for medical necessity.
• Initiate and respond to correspondence regarding medical determinations.
• Ensure accurate and timely reviews of treatment plans.

Skills

Verbal communication

Written communication

Organizational skills

Education

Registered Nurse (RN) license

Tools

Microsoft Word

Microsoft Excel

Health insurance databases

Job description

Job Title: Utilization Review Nurse

Location: Remote, must reside in IL or TX

Duration: August 2025 to December 2025 (possible extension)

Pay rate: $41.45/hr on W2

Description:

Training is for 2 weeks and will be Mon-Fri 8-430

this is full time remote, but candidates must reside in IL or TX

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.