Eligibility: Candidates from only TX, IL, OK, NM, TN only

Role Description

This is a contract and remote position for a Registered Nurse (RN) Utilization Review Nurse. The role involves evaluating medical necessity, utilization review, and authorization of healthcare services to ensure quality and cost-effective care. Primary responsibilities include assessing medical records, collaborating with healthcare providers, maintaining compliance with regulatory standards, and documenting case reviews and decisions. The RN Utilization Review Nurse will communicate with medical teams, insurance providers, and patients to coordinate care effectively.

Qualifications

Current and active Registered Nurse (RN) license
Proficiency in medical necessity reviews, utilization management, and authorization processes
Strong analytical and critical thinking skills, with experience in evaluating medical records
Effective communication skills for collaborating with medical providers, patients, and insurance representatives
Knowledge of regulatory and compliance standards related to utilization review
Proficiency in using medical documentation systems and associated software
Flexibility to work remotely and independently
Case management certification (CCM) and experience with health insurance claims are a plus