Job Title: Quality Review Specialist
Location: Remote in NM, TX, IL, OK, MT
Pay: $38.27/hr on W2
Duration: 6+ months contract to hire
Description:
Applicants must hold an active RN or LPN/LVN license in good standing.
This is a M-F shift 40 hours per week, but mandatory to work holidays (rotating scheduled 3-4 holidays per year) and one weekend every 3rd weekend.
1.Work closely with Utilization Management (UM), Case Management (CM) and Customer Service (CS) to ensure appeal process meets established guidelines.
2.Adhere to accreditation and regulatory requirements to improve customer service and achieve organizational goals related to complaint and appeal resolution.
3.Manage individual inventory through appropriate workflow.
4.Facilitate final resolution of member and provider appeals.
5.Participate in department initiatives related to NCQA and URAC audits, DOI audits, revision project, audits, and correspondence revision projects.
JOB REQUIREMENTS:
Applicants must hold an active RN or LPN/LVN license in good standing.
Bachelor's Degree OR 4 years in health care experience.
5 years utilization management, appeals, claims and mainframe system experience.
Experience in health operations.
Experience with internal/external customer relations.
Knowledge of managed care processes.
Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards.
Knowledge of state and federal health care and health operations regulations.
Organizational skills and ability to meet deadlines and manage multiple priorities.
Verbal and written communication skills to include interfacing with staff across organizational lines plus interfacing with members and providers.
PC proficiency to include Microsoft Word, Access, and Excel.
PREFERRED JOB REQUIREMENTS: Appeals or Utilization management experience