Utilization Review Nurse

Utilization Review Nurse

Job Description

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 with at least 2 years within the hospital setting or direct patient care.

Required Qualification(s):
The RN should have at least 2 years of direct patient care in a hospital or clinical setting.

Notes:
Remote

VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.