Quality Review Specialist

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. Adhere to compliance with external regulatory and accreditation standards.
6.Facilitate access to appeal files by members or member designee under federal guidelines.
7 .Appropriately document data for required reporting and ensure audit readiness.
8.Work directly with members and providers to resolve appeals.
9. Support other team members in appeal resolution and in fulfilling other department responsibilities.
10. Assist in maintaining working relationships across organizational lines.
11. Ensure our member/providers requirements are met at all times.
12. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
13. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
14. Maintain complete confidentiality of company business.
15. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:
Applicants must hold an active RN 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.


Required Qualification(s)
Applicants must hold an active RN license in good standing.



Notes:
This is a M-F shift 40 hours per week, with MANDATORY holiday and weekend rotations. Holidays rotation scheduled 3-4 holidays per year and one weekend every 3rd weekend.
Fully remote opportunity available to applicants in any of our U.S. States except NY, CA, and AK