Qualified Recruiter
This contract role as a Remote Utilization Review Nurse must be a Registered Nurse working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan.
Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation. Awareness of claims processes and claims processing systems. PC proficiency to include Microsoft Word and Excel and health insurance databases. Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings. Organizational skills and prioritization skills. Registered Nurse (RN) with unrestricted license in state. 3 years clinical experience.
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Responsible for performing accurate and timely medical review of claims suspended for medical necessity, contract interpretation and pricing. Initiate and/or respond to correspondence from providers or members concerning medical determinations.
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