3 days ago Be among the first 25 applicants
This is full-time remote, but candidates must reside in IL or TX
Contract: 12/22/2025 to 03/31/2026
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 .