Utilization Review Nurse - RN

24-Hour HR Process Outsourcing, Inc.; Chicago (IL); Remote; USD 70,000 - 85,000; Full time

Job summary

A leading HR process outsourcing company is looking for a Utilization Review Nurse (RN) to join their team. The ideal candidate will possess clinical expertise along with knowledge of healthcare regulations to ensure effective patient care management. This remote position requires a dedicated professional who has a strong understanding of claims processes and the ability to communicate effectively with various stakeholders.

Qualifications

• 3 years of clinical experience required.
• Knowledge of URAC, NCQA standards and health insurance legislation.
• Ability to communicate findings effectively to physicians and members.

Responsibilities

• Perform medical review of claims for medical necessity.
• Validate treatment plans using medically accepted criteria.
• Respond to provider and member correspondence concerning medical determinations.

Skills

Clinical expertise

Communication skills

Organizational skills

Education

Registered Nurse (RN) License

Tools

Microsoft Word

Microsoft Excel

Job description

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We're Hiring: Utilization Review Nurse - RN!

We are seeking a dedicated and experienced Utilization Review Nurse (RN) to join our team. The ideal candidate will possess clinical expertise and a strong understanding of healthcare regulations to ensure optimal patient care while managing resource utilization effectively.

We're Hiring: Utilization Review Nurse - RN!

We are seeking a dedicated and experienced Utilization Review Nurse (RN) to join our team. The ideal candidate will possess clinical expertise and a strong understanding of healthcare regulations to ensure optimal patient care while managing resource utilization effectively.

Location: 100% remote - but ust be residing and licensed in IL or TX

Role: Utilization Review Nurse - RN

Description

• 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.
  
  

Required Qualification:

• 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.
  
  

Ready to make an impact? Apply now and let’s grow together!

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Other

• Industries

  IT Services and IT Consulting

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