Job Title:
Quality Review Specialist
Location:
United States
Job Type:
W2 Contract
Expected Hours per Week:
40 hours per week
Schedule:
Monday–Friday, 9:00 AM to 5:00 PM, Remote
Pay Range:
$38 per hour
Position Description:
We are seeking an experienced Appeals / Utilization Management Nurse to support the resolution of member and provider appeals in a managed care environment. This role partners closely with Utilization Management, Case Management, and Customer Service teams to ensure appeals are processed in compliance with regulatory, accreditation, and organizational standards while delivering a high level of customer service.
What You’ll Do:
- Collaborate with Utilization Management (UM), Case Management (CM), and Customer Service teams to ensure appeals processes meet established guidelines.
- Facilitate end-to-end resolution of member and provider appeals in compliance with state and federal regulations.
- Manage individual appeal inventory using established workflows while meeting required turnaround times.
- Ensure compliance with NCQA, URAC, DOI, and other regulatory and accreditation standards.
- Participate in NCQA and URAC audits, DOI audits, correspondence revisions, and departmental process improvement initiatives.
- Provide data and reporting required for audits, regulatory reviews, and internal stakeholders.
- Facilitate member or member-designee access to appeal files in accordance with federal guidelines.
- Work directly with members and providers to resolve appeals while maintaining superior customer service standards.
- Serve on departmental workgroups and support cross-functional teams.
- Maintain strong working relationships across organizational lines to achieve operational goals.
- Communicate professionally with leadership, peers, members, and providers.
- Maintain strict compliance with HIPAA, Corporate Integrity, Diversity Principles, and all applicable corporate policies.
- Preserve confidentiality of protected health information and company business.
- Communicate workflow updates, trends, and development needs to management; complete special projects as assigned.
What We’re Looking For:
- Active RN or LPN/LVN license in good standing.
- Bachelor’s degree or 4+ years of healthcare experience.
- 5+ years of utilization management, appeals, claims, and mainframe system experience.
- Experience in healthcare operations and managed care environments.
- Strong knowledge of NCQA and URAC accreditation standards.
- Knowledge of state and federal healthcare and health operations regulations.
- Strong organizational skills with the ability to manage multiple priorities and deadlines.
- Excellent verbal and written communication skills with internal teams, members, and providers.
- Proficiency in Microsoft Word, Excel, and Access.
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