Job Description

Remote position, however, candidates must reside in the State of TX or State of IL.

This position is a contract for about 9 months.

Pay: $41/hour

Job Responsibilities:

RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan. This position is responsible for performing accurate and timely medical review of claims suspended for medical necessity, contract interpretation, pricing; and to initiate and/or respond to correspondence from providers or members concerning medical determinations.

Qualifications:

1. Knowledge of accreditation, i.e., URAC, NCQA standards and health insurance legislation.
2. Awareness of claims processes and claims processing systems.
3. PC proficiency to include Microsoft Word and Excel and health insurance databases.
4. Verbal and written communication skills with the ability to communicate to physicians, members, and providers and compose and explain document findings.
5. Organizational skills and prioritization skills.
6. Registered Nurse (RN) with unrestricted license in the state.
7. 3 years clinical experience.

Needs to be able to navigate MCG and medical policies with the reviews.

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