Job Title: Utilization Review Nurse (RN)
Contract Duration: 8 months
Location: Richardson, TX (Remote)
Job Description:
We are seeking a Utilization Review Nurse (RN) for an 8-month contract. This remote position will involve reviewing medical claims for necessity, contract interpretation, and pricing, as well as communicating with providers and members regarding medical determinations.
Key Responsibilities:
Review claims for medical necessity and appropriateness using accepted criteria.
Respond to provider/member inquiries and communicate findings clearly.
Maintain accurate documentation of medical reviews and determinations.
Ensure compliance with accreditation standards (e.g., URAC, NCQA).
Required Qualifications:
Current, unrestricted RN license.
3+ years of clinical experience.
Knowledge of URAC, NCQA, and health insurance legislation.
Proficient in Microsoft Word, Excel, and health insurance databases.
Strong communication and organizational skills.
