Utilization Review Nurse

Mindlance; Springfield (IL); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading company in the managed care industry is seeking a Registered Nurse (RN) for a remote position. The role involves reviewing medical necessity for claims, interacting with providers, and maintaining documentation. Ideal candidates should possess strong communication and organizational skills, with a minimum of 3 years of clinical experience.

Qualifications

• Must have an unrestricted RN license in the state of residence.
• At least 3 years of clinical experience required.
• Knowledge of URAC and NCQA standards preferred.

Responsibilities

• Perform medical review of claims for necessity and appropriateness.
• Initiate and respond to correspondence regarding medical determinations.
• Utilize criteria to validate treatment plans.

Skills

Verbal communication

Written communication

Organizational skills

Prioritization skills

Education

Registered Nurse (RN) license

Tools

Microsoft Word

Microsoft Excel

Job description

Training is scheduled for 2 weeks, Monday through Friday, from 8:00 AM to 4:30 PM.
Max bill rate is ***/hour.
This is a full-time remote position; candidates must reside in Illinois (IL) or Texas (TX).

Job Description: RN working in the insurance or managed care industry, utilizing medically accepted criteria to validate the medical necessity and appropriateness of treatment plans. Responsible for performing accurate and timely medical review of claims suspended for medical necessity, contract interpretation, and pricing. Initiates and responds to correspondence from providers or members regarding medical determinations.

Qualifications and Knowledge: Knowledge of accreditation standards such as URAC and NCQA, health insurance legislation, claims processes, and claims processing systems. PC proficiency, including Microsoft Word and Excel, and familiarity with health insurance databases. Excellent verbal and written communication skills to interact with physicians, members, and providers, and to document findings clearly. Strong organizational and prioritization skills. Must be a Registered Nurse (RN) with an unrestricted license in the state of residence and have at least 3 years of clinical experience.

EEO Statement:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of minority, gender, disability, religion, LGBTQI+, age, or veteran status.