Clinical Quality Review Specialist (RN) – Work From Home

Job Summary

This position is responsible for facilitating member and provider appeals; working closely with Medical Directors and Customer Service to ensure appeal process meets established guidelines. Adhering to accreditation and regulatory requirements to meet audit standards. Managing individual inventory through appropriate workflow.

JOB REQUIREMENTS

• Registered Nurse (RN) with unrestricted license in state of operations.
• 5 years combine knowledge of healthcare processes.
• Knowledge of managed care processes.
• 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 experience to include Microsoft Word, Access, and Excel.

PREFERRED JOB REQUIREMENTS

• Bachelor's degree.
• Utilization management experience.
• Health claims and mainframe system experience.
• Experience with internal/external customer relations.
• Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards.
• Knowledge of state and federal health care and health operations regulations.
• Work Hours are 9 AM to 5:30 PM CST Monday through Friday, with occasional late shift coverage and rotating weekends/holidays.

This is a Remote/Work-From-Home role.

Sponsorship is not available

This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii.

Base Pay Range

$69,800.00 - $125,900.00