Utilization Review Nurse
New
H
HireOps StaffingHealth insurance
Remote position, however, candidates must reside in the State of TX or State of ILContractMiddle
Salary41 USD per hour
Apply NowOpens the employer's application page
Job Details
- Experience
- 3 years clinical experience.
- Required Skills
- Microsoft Excel
Requirements
- Hold Registered Nurse (RN) status with an unrestricted license in state.
- Have 3 years of clinical experience.
- Have knowledge of accreditation standards, including URAC and NCQA.
- Have knowledge of health insurance legislation.
- Be aware of claims processes and claims processing systems.
- Be proficient with PCs, including Microsoft Word and Excel.
- Be able to use health insurance databases.
- Be able to navigate MCG and medical policies for reviews.
- Have organizational and prioritization skills.
- Have verbal and written communication skills for communicating with physicians, members, and providers and explaining documented findings.
Responsibilities
- Use medically accepted criteria to validate the medical necessity and appropriateness of treatment plans.
- Perform accurate and timely medical reviews of claims suspended for medical necessity, contract interpretation, or pricing.
- Initiate and respond to correspondence from providers or members concerning medical determinations.
- Navigate MCG and medical policies while conducting reviews.
- Document and explain review findings.
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