Utilization Review Nurse - RN

24-Hour HR Process Outsourcing, Inc.; Richardson (TX); Remote; USD 75,000 - 100,000; Full time

Job summary

A leading HR outsourcing company is seeking a dedicated Utilization Review Nurse (RN) to ensure optimal patient care and effective resource utilization remotely. The ideal candidate will possess strong clinical expertise, familiarity with healthcare regulations, and the ability to communicate effectively with various stakeholders. Candidates must be licensed in Illinois or Texas and have at least three years of clinical experience, making this an excellent opportunity for mid-senior level professionals in the healthcare insurance space.

Qualifications

• Registered Nurse with an unrestricted license in the state of residence.
• At least 3 years of clinical experience.
• Knowledge of health insurance legislation.

Responsibilities

• Validate the medical necessity and appropriateness of treatment plans.
• Perform medical review of claims and respond to inquiries from providers.
• Ensure compliance with accreditation standards.

Skills

Communication skills

Organizational skills

Clinical expertise

Knowledge of accreditation standards

Education

Registered Nurse (RN) license

Tools

Microsoft Word

Microsoft Excel

Job description

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 - must 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, and pricing; and for initiating and/or responding to correspondence from providers or members concerning medical determinations.

Required Qualifications:

• Knowledge of accreditation standards such as URAC, NCQA, and health insurance legislation.
• Awareness of claims processes and claims processing systems.
• Proficiency in Microsoft Word, Excel, and health insurance databases.
• Verbal and written communication skills to effectively communicate with physicians, members, and providers, and to document findings clearly.
• Organizational and prioritization skills.
• Registered Nurse (RN) with an unrestricted license in the state of residence and at least 3 years of clinical experience.

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Other

Industries

• IT Services and IT Consulting