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Quality Review Specialist (RN or LPN/LVN)

100% Remote (Within US)

6.0 Months

Full-Time $17-$22/hr

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Posted: Jul 28, 2026

Ref: KBILQR28

Position Overview

Work closely with Utilization Management (UM), Case Management (CM) and Customer Service (CS) to ensure appeal process meets established guidelines.
Adhere to accreditation and regulatory requirements to improve customer service and achieve organizational goals related to complaint and appeal resolution.
Manage individual inventory through appropriate workflow.
Facilitate final resolution of member and provider appeals.
Participate in department initiatives related to NCQA and URAC audits, DOI audits, revision project, audits, and correspondence revision projects.
Serve on workgroups.
Adhere to compliance with external regulatory and accreditation standards.
Facilitate access to appeal files by members or member designee under federal guidelines.
Provide data for required reporting. 10.Work directly with members and providers to resolve appeals.
Support other team members in appeal resolution and in fulfilling other department responsibilities.
Assist in maintaining working relationships across organizational lines.
Ensure our member/providers requirements are met at all times.
Communicate and interact effectively and professionally with co-workers, management, customers, etc.
Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
Maintain complete confidentiality of company business.
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 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.

Notes:
Fully remote
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.
This is a contract role with the possibility of conversion to full-time based on business needs and performance

VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

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Competitive Benefits

Your well-being Matters

Health & Future Fully Covered

At VIVA, employee well-being is paramount. Our comprehensive benefits package ensures your health, financial security, and quality of life are always prioritized.

Health Insurance

VIVA provides employees access to a comprehensive group health insurance plan (Medical, Dental, Vision, Basic Life, Term Life, and Accidental Death) through our flexible PPO plan-allowing you the freedom to choose healthcare providers.

401(k) Retirement Planning

Plan securely for your future with automatic payroll deductions into a tax-advantaged 401(k) retirement plan, including employer-matching contributions for eligible employees.

Performance Bonuses & Referrals

Earn performance-based bonuses and generous referral incentives of up to $500 when recommending talented candidates who become part of the VIVA family.

Biweekly Direct Deposit

Enjoy timely and convenient payroll with biweekly direct deposit to your chosen financial institution. Biweekly Direct Deposit

VIVA Perks Program

Access exclusive employee discounts and savings on electronics, travel, groceries, apparel, and more through our dedicated VIVA Perks Program.

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