Utilization Review Nurse – Contract

This is a fully remote position, open to applicants in Illinois, +1 more state.

📋 Description

• The RN will operate within the insurance or managed care sector, utilizing medically accepted criteria to assess the medical necessity and suitability of treatment plans.

• Conducting precise and prompt medical reviews of claims that have been suspended due to medical necessity, contract interpretation, or pricing issues.

• Initiating and/or responding to inquiries from providers or members regarding medical determinations.

• Familiarity with accreditation standards such as URAC and NCQA, as well as health insurance regulations.

• Understanding of claims processing procedures and systems.

• Proficiency in PC applications, including Microsoft Word, Excel, and health insurance databases.

• Strong verbal and written communication skills, capable of effectively interacting with physicians, members, and providers, as well as documenting and clarifying findings.

• Excellent organizational and prioritization abilities.

⛳️ Requirements

• Must be a Registered Nurse (RN) with an unrestricted license in the state.

• A minimum of 3 years of clinical experience is required.

• Ability to navigate MCG and medical policies during reviews is essential.

🏝️ Benefits

• Competitive salary and benefits package.

• Opportunities for professional development and continuing education.

• Supportive work environment promoting work-life balance.