Utilization Review Nurse - Remote - Contract

HireOps Staffing, LLC; Chicago (IL); Remote; USD 100,000 - 125,000; Full time

Job summary

An established industry player is seeking a dedicated Registered Nurse for a remote contract position in the insurance or managed care sector. This role involves validating treatment plans and performing thorough medical reviews on claims. Candidates must possess strong communication skills to interact with physicians and members, alongside proficiency in Microsoft tools and health insurance databases. This is a fantastic opportunity for a skilled RN looking to make a significant impact in the healthcare industry while working remotely.

Qualifications

• Registered Nurse with unrestricted license and 3 years clinical experience.
• Knowledge of accreditation standards and health insurance legislation.

Responsibilities

• Perform medical review of claims for necessity and appropriateness.
• Communicate effectively with providers and members regarding determinations.

Skills

Verbal Communication

Written Communication

Organizational Skills

Prioritization Skills

Education

Registered Nurse (RN) License

Tools

Microsoft Word

Microsoft Excel

Health Insurance Databases

Job description

Remote position, however, candidates must reside in the State of TX or State of IL.

This position is a contract for about 9 months.

Pay: $41 / hour

The RN will work 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.

Required knowledge includes accreditation standards (i.e., URAC, NCQA) and health insurance legislation. Awareness of claims processes and claims processing systems is essential. PC proficiency is required, including Microsoft Word, Excel, and health insurance databases. Strong verbal and written communication skills are necessary to effectively communicate with physicians, members, and providers, as well as to compose and explain document findings. Organizational and prioritization skills are also important.

Minimum Requirements:

1. Registered Nurse (RN) with unrestricted license in state.
2. 3 years clinical experience.
3. Ability to navigate MCG and medical policies during reviews.