Utilization Review Nurse
Epitec
Location: Full-time remote, W2 Contract (Candidates must reside in IL or TX)
Job Description:
We are seeking a dedicated and experienced Utilization Review Nurse to join our team. The ideal candidate will be a Registered Nurse (RN) with experience in the insurance or managed care industry, utilizing medically accepted criteria to validate the medical necessity and appropriateness of treatment plans.
Responsibilities:
- Perform accurate and timely medical reviews of claims suspended for medical necessity, contract interpretation, and pricing.
- Initiate and respond to correspondence from providers or members concerning medical determinations.
- Utilize knowledge of accreditation standards (URAC, NCQA) and health insurance legislation.
- Demonstrate awareness of claims processes and claims processing systems.
- Exhibit proficiency in PC applications, including Microsoft Word, Excel, and health insurance databases.
- Communicate effectively with physicians, members, and providers, and compose and explain document findings.
- Display strong organizational and prioritization skills.
Qualifications:
- Registered Nurse (RN) with an unrestricted license in the state.
- Minimum of 3 years of clinical experience.
- Strong verbal and written communication skills.
- Proficiency in Microsoft Word, Excel, and health insurance databases.
- Knowledge of accreditation standards (URAC, NCQA) and health insurance legislation.
- Awareness of claims processes and claims processing systems.
- Excellent organizational and prioritization skills.
About Us
EpitecCompany Information
EpitecHouston
