Utilization Review Nurse

Integrated Resources, Inc ( IRI ); Springfield (IL); Remote; USD 80,000 - 85,000; Full time

Job summary

A leading company in IT Services and Consulting is seeking a Utilization Review Nurse for a full-time remote position. The role requires a Registered Nurse with strong clinical and communication skills, responsible for validating treatment plans in the insurance industry. Candidates must reside in IL or TX and have a minimum of 3 years experience.

Qualifications

• Minimum of 3 years clinical experience required.
• Knowledge of accreditation standards (URAC, NCQA).
• Understanding of health insurance legislation.

Responsibilities

• Perform accurate and timely medical review of claims for medical necessity.
• Validate treatment plans using accepted medical criteria.
• Interact with providers and members regarding medical determinations.

Skills

Communication

Organizational skills

Prioritization

Education

Registered Nurse (RN) license

Tools

Microsoft Word

Microsoft Excel

Health insurance databases

Job description

Join to apply for the Utilization Review Nurse role at Integrated Resources, Inc (IRI).

Job Title: Utilization Review Nurse

Pay Rate: $40-41.45/hr on W2

Location: Remote in IL/TX

Duration: 6 Months

Summary:

• Training is for 2 weeks, Mon-Fri 8:00-4:30
• 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 responding to correspondence from providers or members concerning medical determinations
• Knowledge of accreditation standards (URAC, NCQA) and health insurance legislation
• Awareness of claims processes and systems
• Proficiency in Microsoft Word, Excel, and health insurance databases
• Excellent verbal and written communication skills to interact with physicians, members, and providers, and to document findings
• Strong organizational and prioritization skills
• Registered Nurse (RN) with an unrestricted license in the state
• Minimum of 3 years clinical experience

Additional Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Other
• Industries: IT Services and IT Consulting

This job posting is active. No indications of expiration are present.