Clinical Quality Review Spec

Health Care Service Corporation • Chicago, IL

128d • $60,300 - $133,400 • Remote

About The Position

This position is responsible for facilitating member and provider appeals; working closely with full-service unit (FSU), provider telecommunication center (PTC), and medical management department (MMD) to ensure appeal process meets established guidelines. Adhering to accreditation and regulatory requirements. Participating in department initiatives related to CMS audits, DOI audits, revision project, audits, and correspondence revision projects; and managing individual inventory through appropriate workflow. Also, conducting audits as well as monitoring ongoing quality improvement activities within the utilization management team; analyzing compliance with department policies, regulatory and accrediting requirements, and preparing reports for management presentation to internal ancillary departments and committees; and serving as a resource to internal ancillary departments on quality and utilization issues and contributing to accreditation survey process.

Requirements

• Registered Nurse (RN) with unrestricted license in state of operations.
• 5 years combined 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.
• Knowledge of UM/CM policies and practices.
• Knowledge or experience of Post-Acute Reviews.
• Quality Improvement experience.
• Analytical Skills.
• Utilization Management Background.

Nice To Haves

• 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 CMS standards.
• Knowledge of state and federal health care and health operations regulations.

Responsibilities

• Facilitate member and provider appeals.
• Work closely with full-service unit (FSU), provider telecommunication center (PTC), and medical management department (MMD).
• Ensure appeal process meets established guidelines.
• Adhere to accreditation and regulatory requirements.
• Participate in department initiatives related to CMS audits, DOI audits, and correspondence revision projects.
• Manage individual inventory through appropriate workflow.
• Conduct audits and monitor ongoing quality improvement activities within the utilization management team.
• Analyze compliance with department policies, regulatory and accrediting requirements.
• Prepare reports for management presentation to internal ancillary departments and committees.
• Serve as a resource to internal ancillary departments on quality and utilization issues.
• Contribute to accreditation survey process.

Benefits

• Health and wellness benefits.
• 401(k) savings plan.
• Pension plan.
• Paid time off.
• Paid parental leave.
• Disability insurance.
• Supplemental life insurance.
• Employee assistance program.
• Paid holidays.
• Tuition reimbursement.
• Annual incentive bonus plan.

What This Job Offers

• Job Type: Full-time
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree