Utilization Review Nurse
New
H
HireOps StaffingHealth Insurance
United StatesContractMiddle
Salary41 USD per hour
Apply NowOpens the employer's application page
Job Details
- Experience
- 3 years clinical experience
- Required Skills
- Microsoft Excel
Requirements
- Registered Nurse (RN) with an unrestricted license in the state of residence.
- Minimum of 3 years of clinical experience.
- Proficiency in navigating MCG and medical policies.
- Proficiency with Microsoft Word and Excel.
- Experience with health insurance databases.
- Knowledge of accreditation standards such as URAC and NCQA.
- Understanding of health insurance legislation and claims processing systems.
- Strong verbal and written communication skills to interact with physicians, members, and providers.
- Strong organizational and prioritization skills.
Responsibilities
- Perform accurate and timely medical review of claims suspended for medical necessity, contract interpretation, and pricing.
- Initiate or respond to correspondence from providers or members concerning medical determinations.
- Validate the medical necessity and appropriateness of treatment plans using medically accepted criteria.
- Maintain knowledge of accreditation standards such as URAC and NCQA and health insurance legislation.
- Navigate MCG and medical policies to conduct reviews.
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