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Utilization Review Nurse/Appeals RN
Job in
Richardson, Dallas County, Texas, 75080, USA
Listed on 2026-02-16
Listing for:
w3r Consulting
Full Time
position Listed on 2026-02-16
Job specializations:
-
Nursing
Healthcare Nursing, RN Nurse, Clinical Nurse Specialist
Job Description & How to Apply Below
- 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.
Qualification:
- 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
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