Utilization Review Nurse-Remote-Contract

HireOps Staffing, LLC; Dallas (TX); Remote; USD 46,597 - 66,365; Full time

Job summary

An established industry player is seeking a dedicated Registered Nurse for a remote contract position focused on reviewing medical claims within the insurance sector. This role involves validating treatment plans using accepted criteria and requires strong communication skills to interact with providers and members. Ideal candidates will possess a solid understanding of accreditation standards and claims processes, along with the ability to navigate medical policies effectively. Join a dynamic team where your expertise will directly impact healthcare outcomes and ensure the appropriateness of treatment plans. This opportunity is perfect for those looking to make a meaningful difference in the managed care industry.

Qualifications

• 3 years clinical experience required for this RN position.
• Knowledge of claims processes and health insurance legislation is essential.

Responsibilities

• Perform medical review of claims for medical necessity and appropriateness.
• Initiate and respond to correspondence regarding medical determinations.

Skills

Verbal and written communication skills

Organizational skills

Prioritization skills

PC proficiency (Microsoft Word, Excel)

Knowledge of accreditation standards (URAC, NCQA)

Claims processes awareness

Education

Registered Nurse (RN) with unrestricted license

Tools

MCG

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

Job Responsibilities:

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:

1. Knowledge of accreditation, i.e., URAC, NCQA standards and health insurance legislation.
2. Awareness of claims processes and claims processing systems.
3. PC proficiency to include Microsoft Word and Excel and health insurance databases.
4. Verbal and written communication skills with the ability to communicate to physicians, members, and providers and compose and explain document findings.
5. Organizational skills and prioritization skills.
6. Registered Nurse (RN) with unrestricted license in the state.
7. 3 years clinical experience.

Needs to be able to navigate MCG and medical policies with the reviews.