Job Description

This is full-time remote, but candidates must reside in IL or TX

Contract: 05/05/2025 to 12/31/2025

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:

• 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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