RemoteCandidates must reside in Illinois or Texas.
Medical, Clinical & Veterinary
About the job
Requirements
Registered Nurse with an unrestricted license in the state of practice.
At least 3 years of clinical experience.
Knowledge of accreditation standards, including URAC and NCQA, and health insurance legislation.
Awareness of claims processes and claims-processing systems.
Proficiency with Microsoft Word, Microsoft Excel, personal computers, and health insurance databases.
Ability to communicate verbally and in writing with physicians, members, and providers, and to compose and explain document findings.
Organizational and prioritization skills.
Ability to navigate MCG and medical policies during reviews.
Responsibilities
Perform accurate and timely medical reviews of claims suspended for medical necessity, contract interpretation, or pricing.
Initiate and/or respond to correspondence from providers or members concerning medical determinations.
Use medically accepted criteria to validate the medical necessity and appropriateness of treatment plans.
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
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.
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.
Needs to be able to navigate MCG and Medical policies with the reviews.